Britishjournal of Dermatology (1978) 99, 77.

Pharmacology and Treatment

Oral photochemotherapy in thetreatment of hchen planus (LP)

CLINICAL RESULTS, HISTOLOGICAL AND ULTRASTRUCTURAL OB-SERVATIONS

J.P.ORTONNE, J.THIVOLET AND C.SANNWALD

F.R.A. INSERM No. 11 'Recherche Dermatologique et Immunologie', Clinique Dermatologique, HopitalEdouard Herriot, 69374 Lyon, Cedex 2, France

Accepted for publication 3 January 1978

SUMMARY

Seven patients with diffuse lichen planus were treated with oral photochemotherapy. Remission waseffected in 6 cases. The only failure may be attributable to a low UVA dose. Histological examinationafter treatment showed disappearance of the superficial derma! lymphocytic infiltrate. Ultrastructuralstudy revealed nuclear alterations of keratinocytes and nuclear and cytoplasmic changes in superficialdermal cells.

Various theories concerning the mode of action of photochemotherapy in lichen planus are dis-cussed in the light of these observations.

The clinical and histological features of lichen planus (LP) are well known although the pathogenesisis obscure.

Current modes of treatment of LP are not always very effective. Oral photochemotherapy iseffective in the treatment of mycosis fongoides (Gilchrest et al, 1976) which is characterized byproliferation of T lymphocytes in the skin. With treatment, the cellular infiltrate disappears for ill-defined reasons (Hjorstshoj & Schmidt, 1977; Roenigk, 1977). As the infiltrate of LP is almost en-tirely composed of T lymphocytes (Alario et al, 1978; Tan, Byron & Hayes, 1975; Walker, 1976;Shousha & Svirbely, 1977)) ^he use of PUVA therapy in the treatment of this condition seemedlogical.

The present study describes the beneficial effect of oral photochemotherapy with methoxsalen andUVA in patients with LP. Histological examination of lesional skin before and after treatment andultrastructural examination in the course of treatment were carried out.

Reprint requests: Dr J.P.Ortonne, Clinique Dermatologique, Hopital Edouard Herriot, 69374 Lyon, Cedex 2,France.

0007-0963/78/0700 oo77$02-oo ©1978 British Association of Dermatologists

77

•78 J.P.Ortonne, J.Thivolet and C.Sannwald

MATERIAL AND METHODS

SubjectsSeven patients (5 females and 2 males) with widespread lesions of LP were studied. In each case thediagnosis was confirmed histologically. Clinical data concerning these patients are summarized inTable i. None of the patients received any treatment, topical or systemic, in the month prior to PUVAtherapy.

TABLE I. Data for patients undergoing photochemotherapy and treatment schedule

Patient Age/sex Skin type Duration No. of Frequency of PUVA Total UVA dosessessions exposures CJ /cm')

1 20/F II 6 M 17 3/WK 4/WK 5»2 50/F III 4 M 32 3/WK 1683456

7

8/M69/F

8/M49/F35/F

IIIIVIIIIIIII

3 M4 MI M2 YI M

M,

4821

303030

month; Y,

3/WK3/WK3/WK3/WK3/WK

year.

5/WK5/WK5 /WK

230107

155163126

Light sourcesHexagonal 'stand-up' light boxes containing 84 fluorescent bulbs mounted vertically side by sidewere used as UVA sources. These bulbs have a continuous spectrum of high intensity irradiationbetween 320 and 400 nm with a peak emission at 365 nm. The energy delivered was on average 4-4-5mW/ cm^ at a distance of 50 cm from the bulbs. Dosimetric control of emitted energy was regularlycarried out.

Exposures and dosages (Table i) .Methoxsalen. Ten mg capsules of methoxsalen were given 2h prior to UVA exposure according to

thepatient'sweight:25kgorless, iomgof 8 MOP; 26-45 kg 20 mg of 8 MOP; 46-60 kg, 30 mg of8 MOP; 60-75 kg> 40 mg of 8 MOP; 76-90 kg, 50 mg of 8 MOP; greater than 90 kg: 60 mg of 8MOP.

UVA dosage. Initial exposure times were based on the skin type (Fitzpatrick, 1975)- The initialUVA dose was 15 -2 J/cm^ and was increased at the first and third sessions of each week. The maxi-mum dose administered at the end of treatment never exceeded 7 J/cm^ in a single session. Thepatients were treated three times per week with an interval of 48 h between each session. Where thepatient's tolerance to UVA permitted, the number of weekly sessions was progressively increased to 4and subsequently 5. After the initial programme of treatment, maintenance therapy was not pursued.

EVALUATION OF RESULTS

Glinicai Clinical response was evaluated weekly. Two parameters were monitored: the degree ofpruritus and the palpability of the lesions. The results were recorded as follows: excellent (completeclearing with total flattening of the papules accompianed by residual pigmentation and disappearanceof pruritus), good (partial clearing based on diminution of clinical infiltration of lesions), fair (slight

Oral photochemotherapy for lichen planus 79

improvement) and poor (no improvement). The patients comments and symptoms were also recorded.Photographs were taken of each patient prior to therapy and at weekly intervals.

Histology: Biopsies were taken from all patients before treatment. In one ofthe 7 cases, the histologywas that of lichen planopilaris.

In 6 of the 7 patients, the skin was biopsied at the end of treatment. The results of histologicalgrading were recorded as follows: excellent (disapperance of epidermal abnormalities, and dermalinfiltrate), good (disappearance of epidermal abnormalities, particularly hypergranulosis; persistenceof mild non-epidermotropic infiltrate), fair (persistence of focal hypergranulosis and epidermotro-pism with a moderate dermal lymphocyte infiltrate), poor ("no improvement).

In addition to routine light microscopy, the following techniques were undertaken on biopsymaterial at the end of treatment,

Immtmofluorescence. In three patients, direct immunofluorescence studies were performed, beforeand after photochemotherapy, using standard techniques with fiuorescent conjugates (InstitutPasteur), i,e. anti IgA, anti IgM, anti IgG on frozen sections.

Electron microscopy. In one case (Case i) a biopsy of an abdominal lesion was subjected to ultra-structural examination, after a total dose of UVA of 43 J/cm^ The biopsy specimens were fixed in3"., glutaraldehyde for i h then postfixed in osmic acid for i h, dehydrated in alcohol, embedded inEpon and sectioned on a Reichert ultramicrotome. The specimens were stained with uranyl acetateand examined with a Hitachi HU 12 electron microscope.

RESULTS

Clinical (Fig. i)In 6 ofthe 7 patients treated, the clinical results were considered to be excellent or good (Table 2).After about 2 weeks of treatment, the lesions began to subside. During resolution they developed theappearance of fine powdery hyperkeratosis. At the end of treatment, the lesions appeared only ashyperpigmented macules with variable superficial atrophy. In the seventh patient (Case 4) the res-ponse was only fair. However, the treatment was stopped after a total dose of 107 J/cm^ which is lowerthan was received by the other patients. The treatment of this patient of skin type IV would haverequired much greater doses of UVA. Localized lesions on the elbows or on the shins react much moreslowly than others. No deterioration was seen in any patient.

Pruritus disappeared between the second and the fifth week of treatment. The mean dose of UVArequired for clearing, calculated from the cases with a good response, was 150 + 39 J/cm^ correspon-ding to 31 sessions of therapy. ^X'ith three sessions per week, the average duration of treatment was10 weeks.

No relapses have occurred 2-8 months after stopping treatment. Approximately 4-6 weeks afterthe end of therapy, the mild cutaneous atrophy was no longer detectable. The mucosal lesions persistunchanged.

Undesirable side effects of treatment were nausea in 5 patients and localized blistering in onepatient. Marked dryness ofthe skin was observed in all the patients.

Histological findings (Table 3) (Fig, 2)At the end of treatment, in all cases, the epidermis showed fairly marked orthohyperkeratosis. Thegranular layer was preserved but not hypertrophic. The Malpighian layer was generally atrophic but of

So J.P.Ortonne, J.Thivolet and C.Sannwald

Oral photochemotherapy for lichen planus 8l

TABLE Z. Overall results

Patient

I

II

HI

IVV

VI

vn

Clinical result

Complete clearingexcellentComplete clearingexcellentComplete clearingexcellentFairComplete clearingexcellentComplete clearingexcellentComplete clearingexcellent

Histological result

Good

Excellent

N.D.

FairGood

Good

Good

Pruritus

(6)

(i6)

(?)

—(8)

(15)

(3)

( ) Number of sessions required for the improvement of pruritis.

normal architecture. The basal layer, however showed marked vacuolar change and the dermo-epidermal junction frequently exhibited loss of rete ridge pattern. The basement membrane wasthickened in many cases and in places appeared folded. In some cases, hyaline bodies were observed.Prominent melanin pigmentation was irregularly distributed through the lower half of the epidermis.In addition, there was considerable pigmentary incontinence in the form of large deposits of intra andextracellular melanin. The papillary and upper reticular dermis were either oedematous or hyalinized.In the majority of cases, very deep alterations of elastic tissue were observed. In the papillary dermisthe elastica was very fragmented.

In the reticular dermis the fibres were thinned and sometimes fragmented. In one case, atrophichair follicles were replaced by fibrous tissue. The walls of superficial dermal capillaries were generallythickened and occasionally folded, and they were frequently surrounded by a mild mononuclearinfiltrate. The deep dermis did not show any obvious pathological changes.

ImmunofiuorescenceIn the three cases studied, fluorescence of Civatte bodies was seen particularly with an and IgM con-jugate and very weakly with anti IgG and anti IgA conjugates.

At the end of treatment this fluorescence had disappeared in one case and persisted unchanged inthe other two.

Electron microscopy

Epidermis. In the granular layer abnormal keratinocytes with a deeply indented nucleus wereobserved. In certain sections, these nuclei appeared to consist of two, three or four separate lobules.The nucleoli, at times multiple (2 or 3), were always prominent. Heterochromatin was scarce or evenabsent. Euchromatin at times occupied the entire nucleus. The nuclear membrane was intaa. On theother hand, the plasma membrane had disappeared. Keratohyahn granules were quantitatively andquahtatively normal.

In the Malpighian layer there was widening of intercellular spaces without rupture of desmosome-tonofilament complexes. The nuclei showed prominent indentations with always one or two nucleoli.Occasionally the cytoplasm appeared vacuolated.

J.P.Ortonne, J.Thivolet and C.Sannwald

A o

Oral photochemotherapy for lichen planus

TABLE 3. Histological observations after PUVA therapy

EpidermisDermalinfiltrate

Patients Hyperkeratosis

Vacuolizationof basal layer

cellsEpidermalatrophy

Density

IIIIIIIVVVIVII

N.D.

+ +NONEN.D.+ + +++ + +-1-

+ or absent-1- or absentN.D.-I- or absent-j- or absent-1- or absent+ or absent

(90)(100)

N.D.(60)(90)(90)(90)

N.D.: not done.V'/o)'- /o of the decrease in the dermal infiltrate.

Cellular alteration was particularly obvious in the basal layer (Fig. 3). In some keratinocytes, tono-filaments formed thick perinuclear bundles. Occasional keratinocytes were totally necrosed andnumerous masses of filaments, not limited by a membrane and sometimes containing mature melano-somes, could be observed. The melanocytes were generally very active and contained mostly maturemelanosomes situated almost entirely in the peripheral cytoplasm. Likewise the numerous dendriteswere packed with mature melanosomes. The basement membrane was frequently ruptured. In otherplaces it was convoluted or folded.

FIGURE 3. Severe cellular changes in the basal layer with vacuolated cytoplasm of melanocytes.( i : altered lymphocyte; n: necrotic cell) ( x 5400).

J.P.Ortonne, J.Thivolet and C.Sannwald

FIGURE 4. Dilatation of the perinuclear space in mid-dermal mononuclear cell (S: Sezary like cell)( X 9000). Inset: high-power view of the perinuclear vacuole ( x 54000).

Dermis. The superficial dermis also revealed marked pathological changes. Collagen bundles wereseparated by considerable oedema. The nuclei of fibroblasts and macrophages were indented andshowed multiple convolutions (Figs 5-8). In places the perinuclear space was dilated giving a vacuolarappearance. Very large intracytoplasmic vacuoles were frequently observed. These were bounded by adiscontinuous membrane and tended to squash the nucleus. Mitochondria were generally dilated.

A few cells resembling Sezary cells were also present in the superficial dermis (Fig. 4). Some ofthem showed dilatation of the perinuclear space. Others did not reveal nuclear or cytoplasmic abnor-mahties.

The deep reticular dermis was normal.

DISCUSSION

Lichen planus frequently presents a difficult therapeutic problem. The natural history of the con-dition without treatment is usually prolonged and spontaneous resolution is not invariable (Altmann& Perry, 1961).

Oral photochemotherapy seems to be an eflicient mode of treatment, improving both the itchingand the clinical lesions which become progressively less palpable and finally imperceptible at the endof treatment. Our resuhs agree with Honigsman et ai (i977) who stated that photochemotherapy waseffective in lichen planus. Histology confirms the disappearance of the superficial dermal infiltrate.This regression of lichen planus seen in 6 out of 7 patients is unquestionably due to photochemo-therapy. Indeed, at the end of therapy, a few lichen planus papules may persist in non-exposed areas(inner aspect of the thighs) in many patients. This fact and the persistence unchanged of mucosallesions eliminates the possibility of spontaneous resolution in these cases.

The doses required for clearing are about double those required for clearing psoriasis. In otirexperience they are comparable to those required for the effective treatment of mycosis fongoides.The responses obtained seem to be maintained without further treatment.

Oral photochemotherapy for lichen planus

FIGURES 5-8. Cellular changes in the upper dermis. Fig. 5. Large intercytoplasmic vacuolcs (Va)compressing the nuclear of a fibroblast (E: epidermis) ( x 6000). Fig, 6. Intracytoplasmic vacuole(Va) in a melanophage (Mp: melanophagolysosomes) ( x 4800). Fig. 7, Intracytoplasmic vacuole(Va) in a fibroblast. The cell membrane is destroyed ( x 9600). Fig. 8. Dilation (Vp) of theperinuclear space of a mononuciear cell ofthe dermal infiltrate ( x 20,000). Inset: high power view ofthe perinuclear vacuole (_ x 36,000).

Histological examination carried out after treatment shows profound alterations in the superficialdermis, particularly ofthe elastic fibres. These changes which are not usually present in lichen planusappear to be due to photochemotherapy. The changes in elastic tissue have not been seen in psoriaticstreated with PUVA (Braun Falco, Hofmann & Plewig, 1977). It must be emphasized that our patientsreceived a total dose of UVA considerably in excess of that normally used in the treatment of psoriasis.

86 J.P.Ortonne, J.Thivolet and C.Sannwald

Besides the disappearance of the dermal infiltrate, photochemotherapy produces marked changesin the epidermis of the lesion. The thickness of the granular layer diminishes considerably, as does thethickness of the Malpighian layer. However, photochemotherapy is probably not the sole cause ofepidermal atrophy seen in hchen planus lesions after treatment. Normal epidermis usually reacts tophotochemotherapy by hyperplasia and 'pseudoparakeratosis' (Toda, Nakayama & Morikawa, 1974).This tendency to atrophy after PUVA appears to be specific to lichen planus, further supporting thetheory of an epidermal origin for lichen planus.

We did not find keratohyalin granules in the keratinocytes of the lower half of the Malpighian layer,such as were described in normal epidermis after topical trimethylpsoralen (TMP) and UVA (Toda

et al, 1974)-Ultrastructural study shows changes of the epidermis and superficial dermis which can be classified

in two groups:(1) Anomalies which are known to be due to lichen planus and for which photochemotherapy is not

responsible: colloid bodies, intercellular oedema, changes in desmosome-tonofilament complexes,rupture of the basement membrane (Medecina & Lorincz, 1977).

(2) Anomalies which may be due to photochemotherapy. The nuclear alterations seen in somekeratinocytes (nuclear lobulation, modification of chromatin distribution) probably belong to thisgroup as they have not been observed in untreated Hchen planus (Medecina & Lorincz, 1977).Nucleolar and chromatin changes are observed transitorily in guinea-pig epidermis after injection of8 MOP and UVA irradiation (Mizuno et al, 1974). The indented appearance of keratinocyte nuclei inthe deep part of the Malpighian layer was seen in human epidermis a few hours after local applicationof TMP followed by UVA irradiation (Toda et al, 1974). Specimens which were taken from unin-volved skin of psoriatic patients who had been treated between 20 and 40 times with an oral dose of8 MOP and UVA irradiation revealed the presence of binucleate, tetranucleate and multinucleateepidermal cells (Omar, Wiesmann & Krebs, 1977). It is therefore probable that keratinocyte nucleiare one of the targets of PUVA therapy.

The nuclear or cytoplasmic changes seen in cells of various type (melanophages, fibroblasts,lymphocytes, Sczariform cells) which populate the superficial dermis in lichen planus are probablydue to PUVA therapy. The cells of the dermal infiltrate of untreated lichen planus do not usuallyshow ultrastructural changes (Medecina & Lorincz, 1977) of the type we have observed. Furthermore,the changes seen in the dermal cells are limited to the superficial dermis, localized to an area corres-ponding to that which is usually considered to be the limit of penetration of UVA in human skin(Everett et al, 1966). Nuclear anomalies of superficial dermal fibroblasts have been observed prev-iously in patients treated by PUVA therapy (Omar et al, i^^fi). The cytoplasmic vacuolization whichwe have found only in cells of the basal layer and superficial dermis may be compared to that whichhas been described in psoriatic epidermis treated by photochemotherapy (Vukas, Velfi, & Gligora,1977). It doubtless constitutes a sign of cellular damage caused by photochemotherapy.

The aetiology of lichen planus is unknown. It is therefore difficult to conjecture on the mode ofaction of photochemotherapy in this condition. An autoimmune mechanism has been suggested. Ithas been postulated that in lichen pianus, degenerating epidermal cells stimulate a brisk infiammatoryresponse with resultant hydrolysis of the colloid bodies (Black, 1971, 1972). Lymphocyte transfor-mation has been demonstrated in lymphocytes cultivated in the presence of tissue extracts of lichenplanus (Sarkany & Gaylarde, 1971). Several ultrastructural studies (Johnson & Fry, 1967; Sarkany &Gaylarde, 1971 jEbner, 1973; Medecina & Lorincz, 1977) seem to show that in the evolution of lichenplanus epidermal changes precede dermal changes, particularly the appearance of the infiltrate. It hastherefore been suggested that the initial change in lichen planus is situated in the keratinocyte nucleusof the germinative layer and happens during the initial phase of mitosis. Then an antigen situated at

Oral photochemotherapy for lichen planus 87

this level may be the origin of a cellular immune response. According to this hypothesis two principalfactors are involved: the appearance of a new epidermal antigen and the appearance of a dermallymphocytic infiltrate. Our ultrastructural findings suggest that photochemotherapy may act on bothof these factors. It is possible that the nuclear changes induced in the keratinocytes may modify theappearance of the hypothetical epidermal antigens responsible for the development of lichen planus.Likewise the nuclear and cytoplasmic changes found in the superficial dermal infiltrate suggest thatphotochemotherapy may have a direct ablative action on the lymphocytes. These hypotheses whichrely on morphological data can only be considered as a basis for further study.

ACKNOWLEDGMENTS

The technical assistance of Miss Agnes Micoud is gratefully acknowledged.

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