Direct Immunofluorescence Studies in Lichen Planus
Supriya JAIN1, Vijaya BASAVARAJ2
1Department of Pathology, Bharati Vidyapeeth (deemed to be university) Medical College and Hospital, SANGLI, INDIA
2J.S.S Medical College, J.S.S. University, MYSORE, INDIA
Keywords: Lichen planus, Lupus erythematosus, Direct immunofluorescence
Lichen planus is a common, usually intensely pruritic, symmetrical, papulosquamous dermatosis. Direct immunofluorescence studies
in patients with lichen planus shows deposition of multiple immunoglobulins and fibrin at the dermoepidermal junction and in the colloid
Material and Method: Histopathological features were analysed in 100 cases of lichen planus which were sent for routine histology. Direct
immunofluorescence studies were done in 22 out of the 100 cases and the features were analysed. Clinical data was recorded from patient files.
Results: Positive direct immunofluorescence was seen in 78.5% of the cases. Deposits at the dermoepidermal junction and colloid bodies were
detected in 88% and 40% of the cases respectively. IgG, IgM and C3 deposition was seen in 88%, 70% and 24% respectively. IgA was negative in
all the cases.
Conclusion: The linear and shaggy deposition of immunoreactants in a discontinuous form along the dermoepidermal junction and in the
colloid bodies were indicators in support of lichen planus along with the characteristic histopathological findings. In lupus erythematosus, linear
and granular deposition of immunoglobulins in a continuous form is found along the dermoepidermal junction. Direct immunofluorescence
studies are of immense help in disease differentiation in cases of interface dermatitis with no specific histological or clinical characteristics and
in cases with ambiguous features.
Lichen Planus (LP) is a common inflammatory disease of
unknown etiology characterized by violaceous and flattopped
papules, which are usually pruritic. A network of
fine white lines (Wickham’s striae) may be seen on the
surface of the papules. There is a predilection for the flexor
surface of the wrists, the trunk, the thighs and the genitalia
(1). LP frequently occurs between 30 and 60 years of age.
The diagnosis of LP can routinely be done based on clinical
and histopathological examination. Many centers have
routinely employed direct immunofluorescence (DIF)
studies in cases of LP. DIF studies are essentially required in
cases where specific clinical or histological features are not
present. Cases of interface dermatitis can be very intriguing
with ambiguous features in other diseases. e.g. lupus
erythematosus (LE). DIF in previous studies have shown
immunoglobulins, complement and fibrin deposition
in the colloid bodies (CB) and at the dermoepidermal
junction (DEJ) (2). This study was undertaken to evaluate
the utility of DIF studies in LP, and whether DIF studies are
really required in LP.
The study was undertaken at the department of pathology.
Clinically diagnosed cases of LP and its variants which
were sent for histopathological study and DIF studies
were included in the study. The clinical findings and
histopathologic features of a total of 100 cases were studied.
DIF studies were performed on 22 cases and the data for
DIF was analyzed in 22 cases.
The skin punch biopsy specimen for histopathological
study was received in 10% formalin and processed for
routine histology after 24 hrs of fixation in formalin
and studied by light microscopy. The skin punch biopsy
specimen was obtained in normal saline for DIF studies.
The specimen for DIF studies was washed thrice in
Phosphate Buffer Saline (PBS) and snap frozen in OCT
(Optimum Cutting Temperature) medium followed by
cutting of 4 micron thick sections on 4 slides labeled IgG,
IgA, IgM and C3. This was again washed in PBS and treated
with FITC (Fluorescein Iso Thio Cyanate) labelled antisera
respectively and incubated for 1 hr at 37 degrees followed
by washing thrice with PBS and then evaluated under a
Out of the 100 cases (52 males and 48 females) of LP, DIF
studies were done in 22 cases (10 males and 12 females).
Their age ranged from 13 years to 80 years, and the duration
of the lesion ranged from 15 days to 1 year. The most
common site of involvement was the extremities (67 cases)
followed by the trunk (43 cases). Oral lesions were seen in
20 cases and genital involvement in 8 cases, as shown in
. Itching was the most common clinical complaint
seen in 88 cases followed by pigmentation in 42 cases. 50
cases showed papular lesions followed by hyperpigmented
patches in 42 cases, as shown in Table II
Biopsies obtained from the lesions showed various
histopathological features. The epidermis showed compact
orthokeratosis, wedge-shaped hypergranulosis, mild
acanthosis and basal cell vacuolar degeneration in 72 cases.
The remaining cases had only some of these features.
Pointed rete ridges were seen in 41 cases. The dermis
showed a band-like lymphohistiocytic infiltrate along the
dermoepidermal junction (DEJ) abutting the basal cells
and sometimes obscuring the DEJ in 70 cases. CB were seen
in 42 cases. Melanin pigment incontinence was seen in 74 cases, as shown in Table III. The histological features were as
shown in Figure 1. A few cases had features like occasional
cells showing basal cell vacuolar degeneration or mild
pigment incontinence with a few scattered lymphocytes
in the upper dermis and not meeting the criteria for the
diagnosis of classical lichen planus. These were the cases
which required DIF studies to arrive at a final diagnosis.
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|Figure 1: High power view showing epidermal acanthosis and
hyperkeratosis along with saw toothing of rete ridges. There is
basal cell vacuolar degeneration with a band of lympho-histiocytic
infiltrate at the dermoepidermal junction. Melanin pigment
incontinence and Civatte bodies are also noted (H&E; x200).
Out of the 22 cases sent for DIF studies, 17 cases showed
deposition of immunoglobulins accounting to positive DIF
studies in 77% of the cases. The pattern of deposition of
immunoglobulins was focal and shaggy along the DEJ with
irregular fine extensions into the papillary dermis. Of the
17 cases positive for DIF, deposition of IgG was seen in 15
cases accounting for 88%, deposition of IgM was seen in 12
cases accounting for 70%, and deposition of C3 was seen in
4 cases accounting for 24% of the cases. Seven cases showed
deposition of immunoreactants in the colloid bodies
accounting to 40% of the cases. Of the immunoreactants
which were deposited in the colloid bodies, IgG was seen
in all 7 cases, IgM in 4 cases and C3 in 4 cases. (Figure
2-4) IgA was negative in all the cases. The distribution of
immunoreactants was as shown in Table IV.
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|Figure 2: Deposition of IgG in a linear, granular and discontinuous
pattern along the dermoepidermal junction with extension into
papillary dermis in LP (DIF, x200).
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|Figure 3: Deposition of C3 in a continuous linear and granular
pattern along the dermoepidermal junction (DIF; x200).
LP is an immune mediated disease which on DIF studies
shows a linear and shaggy broad band of staining with
fibrinogen, immunoglobulins and complement along the
DEJ. CB in the papillary dermis may show deposition of
immunoglobulins. CB, also known as Civatte bodies, are
eosinophilic hyaline ovoid bodies which are often found
in the subepidermal papillary regions or sometimes in the
epidermis. They are usually seen in LP and LE (3). They
can also be found in several dermatoses such as erythema
multiforme (EM), bullous pemphigoid (BP) and diseases
with suprabasal clefts (4). CB are generally believed to be
derived from two origins. The first type originates from apoptosis of keratinocytes causes by epithelium damage
created by circulating antibodies (5). CB of this type are
usually found locally both in the epidermis and papillary
dermis. The other origin derives from the destruction of
thickened basement membranes which are found only in
the papillary dermis. DIF studies help in differentiating
these conditions and hence is essential to arrive at a final
diagnosis in cases with overlapping features.
In our study, the positive DIF yield was 78.5 % whereas
in many previous studies the positive yield ranged from
around 37% to 97% (2,6). In most of the previous studies
the specimen was mostly from oral mucosal lesions.
Annesi et al. reported a positive yield of DIF in 71% of the
cases from scalp lesions with scarring alopecia due to LP
and Kulthanan et al. have reported a positive yield in 73%
of the cases from glabrous skin (2,6). Previous DIF studies
have resulted in deposition of immunoglobulins in around
90% of the cases which is similar to study (2).
Our study showed deposition of immunoreactants and
complement at DEJ and in the CB. The most common
immunoreactant was IgG, which was positive in 88% of the
cases. The other immunoreactants in decreasing order of
frequency were IgM and C3. IgA was negative in all cases.
The results are similar to the results in most of the previous
studies where IgG was the most common immunoglobulin
deposit along DEJ after fibrinogen. Previous studies have
not included uniform reports of the class of immunoreactant
deposited in CB but in our study it was IgG.
Helanders and Rogers have suggested that the diagnostic
sensitivity of LP by presence of CB alone is poorer, and it is
better defined by shaggy deposits of immunoglobulins and
complement along DEJ. However, CB in LP demonstrate a
tendency to cluster in groups of 10 or more in the papillary
Morphologically identical deposits of immunoglobulins
in colloid bodies and at the DEJ may be found in LP and
LE, and DIF studies play a significant role in distinguishing
them. This distinction becomes all the more important
in cases where histopathological and clinical findings are
overlapping and non diagnostic.
DIF studies in LP show deposition of immunoreactants and
fibrin along the DEJ in a broad discontinuous and shaggy
pattern along with colloid body deposition. LE lesions are
likely to contain linear band-like deposits of Ig and C3 in
the DEJ. If IgM is present, there is a high probability that
the patient has LE, and C3 deposition also occurs more
frequently in LE than in LP. The pattern of staining in LE is
linear, granular, broad, discontinuous band-like but it may
also be smooth and continuous in occasional cases.
Schiodt et al. have recommended that granular staining
along DEJ with at least one immunoglobulin in addition to
C3 is necessary for diagnosis of LE (8).
Kok et al. evaluated both direct and indirect IF studies on
patients with cutaneous and oral lichen planus and found
that although DIF studies showed deposition of fibrin in a
granular or shaggy pattern in a considerable percentage of
cases, other immunoglobulins were seen in only a minimal
number of cases. They did not find a significant level of
circulating immune complexes in patients with LP. These observations made them rule out the possibility of immune
complexes playing a significant role in the pathogenesis of
LP. The authors comment that deposition of fibrinogen is
nonspecific and can also be seen in the skin and corneal
wound and in many immune mediated reactions and
hence they consider that fibrin deposition is non-specific
and a part of the homeostatic mechanism of the body (9).
Immunoreactant deposits at CB alone can be found in
various diseases but a strong intensity and high quantity
favor the diagnosis of interface dermatitis. CB plus
DEJ deposits are more common in interface dermatitis
than in any other disease. Between lichen planus and
lupus erythematosus, CB alone is more common in LP
whereas the combination of CB plus DEJ and superficial
blood vessels is more common in LE. The most common
pattern in both diseases is CB plus DEJ. Although both
LP and LE show overlapping results regarding the type
of immunoglobulin deposition on DIF, the pattern
of deposition makes the difference. In our study, LP
consistently showed a shaggy deposition along the DEJ
with irregular extensions into papillary dermis as shown in
Figure 2 and 3. The quantity and intensity of CB in LP is
higher than in LE and is shown in Figure 4. In comparison,
cases of LE show broad, continuous, linear and granular
deposition of immunoreactants confined to the basement
membrane zone without extensions into the papillary
dermis or epidermis as shown in Figure 5. The shaggy
irregular deposits are characteristic of LP. LE lesions are
likely to contain deposits of immunoglobulins and C3 in
the DEJ. If IgM is present in a discontinuous band-like
pattern, there is high probability that the patient has LE. C3
deposition occurs more frequently in LE than in LP Oral LP poses a diagnostic dilemma clinically. The clinical
differential diagnosis of oral lichen planus includes
lichenoid drug eruptions, lichenoid lesions associated
with contact hypersensitivity to restorative materials,
leukoplakia, lupus erythematosus and graft versus host
disease (10). DIF studies help in distinguishing oral LP from
other lesions such as pempgius vulgaris, benign mucous
membrane pemphigoid and linear IgA bullous dermatosis
(11). DIF has a more significant role in the diagnosis of oral
LP than cutaneous LP.
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|Figure 5: Deposition of IgG in a broad, continuous, linear and
granular pattern along the dermoepidermal junction in a case of
lupus erythematosus (DIF; x400).
In summary, the positive yield of direct immunofluorescence
in the present study was 78.5%. Shaggy deposition
of immunoreactants and especially IgG and the
deposition of immunoreactants in colloid bodies were
the indicators of diagnosis of LP with the support of
characteristic histopathology findings. In the present study,
histopathological features were diagnostic in the majority
of the cases. DIF studies were supplementary in such cases.
However, DIF studies are of immense help in cases with
ambiguous histological and clinical features. Hence, the
authors suggest that DIF studies need not be routinely
employed in all cases of LP as they are not cost-effective
and should be resorted to only when the histopathological
study and clinical features are non-contributory.
We would like to conclude that DIF studies in cases of
interface dermatitis are required only in cases where
the histopathology is ambiguous. DIF studies are more
beneficial in oral LP as compared to cutaneous LP and
DIF studies are of immense help in cases with overlapping
features between LP and LE. The limitation of the present
study was the non availability of anti fibrinogen. However,
the pattern of deposition of other immunoglobulins in a
shaggy manner was conclusive enough to support the
diagnosis of LP.
CONFLICTS of INTEREST
The authors declare no conflict of interest
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