Lichen planus

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Lichen planus


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USMLE® Step 1 questions

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Lichen planus

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USMLE® Step 1 style questions USMLE

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A 37-year-old man comes to the office because of itching over his shins for the past few months. The itching is unrelenting and is now interfering with his sleep. He has used several over-the-counter ointments, which have not helped. Past medical history is noncontributory. He is sexually active with a female partner and uses condoms consistently. He has a previous history of IV drug use in his early 20s. Physical examination shows multiple, well-healed track marks on his arms. Examination findings of the shins are shown below.

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Complete blood count is within normal limits. Further testing reveals elevated serum aminotransferase levels. This patient’s condition is associated with which of the following organisms?

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Hepatitis C (HCV)

lichen planus p. 496

Lichen planus p. 171, 487, 495

presentation p. 718

Plaques (skin) p. 487

lichen planus p. 496


lichen planus p. 496


With lichen planus, lichen means tree moss and planus refers to flat, and the reason it’s called that, is that lichen planus is a flat-topped skin rash that looks a bit like tree moss.

Lichen planus is an immune-mediated disorder, meaning that the immune system has started attacking its own skin, resulting in a skin rash.

Lichen planus can also affect mucous membrane.

Now, the skin is divided into three layers--the epidermis, dermis, and hypodermis.

The epidermis forms the thin outermost layer of skin.

Underneath, is the thicker dermis layer that contains the nerves and blood vessels.

And finally, there’s the hypodermis which is made of fat and connective tissue that anchors the skin to the underlying muscle.

The epidermis itself is made of multiple layers of developing keratinocytes - which are flat pancake-shaped cells that are named for the keratin protein that they’re filled with.

Keratinocytes start their life at the lowest layer of the epidermis called the stratum basale, or basal layer, which is made of a single layer of stem cells that continually divide and produce new keratinocytes.

These new keratinocytes then migrate upwards to form the other layers of the epidermis.

The stratum basale also contains another group of cells - melanocytes, which secrete a protein pigment, or coloring substance, called melanin.

As keratinocytes in the stratum basale mature and lose the ability to divide, they migrate into the next layer, called the stratum spinosum which is about 8 to 10 cell layers thick.

The next layer up is the stratum granulosum which is 3 to 5 cell layers thick. Keratinocytes in this layer begin the process of keratinization, which is the process where the keratinocytes flatten out and die.

Keratinization leads to development of the stratum lucidum layer which is 2 to 3 cell layers thick of translucent, dead keratinocytes.

Finally, there’s the stratum corneum, or the uppermost and thickest layer of the epidermis, which is like a wall of 20-30 layers, where the glycolipid acts like the cement and the dead keratinized cells are the bricks.

Now, the part of skin connecting the stratum basale of the epidermis to the underlying dermis is called the dermo-epidermal junction.

In healthy people, this junction looks like smooth waves between the epidermis and the dermis. But, if you look closely at this junction, there are two parts.


  1. "Robbins Basic Pathology" Elsevier (2017)
  2. "Harrison's Principles of Internal Medicine, Twentieth Edition (Vol.1 & Vol.2)" McGraw-Hill Education / Medical (2018)
  3. "Pathophysiology of Disease: An Introduction to Clinical Medicine 8E" McGraw-Hill Education / Medical (2018)
  4. "CURRENT Medical Diagnosis and Treatment 2020" McGraw-Hill Education / Medical (2019)
  5. "Cutaneous and Mucosal Lichen Planus: A Comprehensive Review of Clinical Subtypes, Risk Factors, Diagnosis, and Prognosis" The Scientific World Journal (2014)
  6. "Lichen Planus" New England Journal of Medicine (2012)
  7. "Interventions for erosive lichen planus affecting mucosal sites" Cochrane Database of Systematic Reviews (2012)

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