Biopsy specimens of the violaceous papules revealed compact hyperkeratosis, hypergranulosis, frequent necrotic keratinocytes, and basal layer vacuolization, with a dermal bandlike mononuclear cell infiltrate obscuring the dermoepidermal junction. Eosinophils were present in the infiltrate and in the epidermis. The possibility of autoimmune bullous disease was raised, but was considered less likely than a lichenoid drug eruption due to lisinopril therapy until the patient developed tense vesicles. Direct immunofluorescence of perilesional skin revealed positive linear staining for C3 (Figure 3) and IgG along the dermoepidermal junction. The patient continued to develop vesicles overlying LP-like lesions on the lower extremities as well as on normal skin. A 2-week prednisone taper beginning at 20 mg/d was initiated, with close surveillance of blood glucose levels. The vesicles quickly resolved. The pruritic lichenoid papules persisted but are responding to resumed treatment with narrowband UV-B.
Vesicles in a Patient With a Lichenoid Eruption—Diagnosis. Arch Dermatol. 2003;139(10):1363–1368. doi:10.1001/archderm.139.10.1363-a
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