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The physical examination revealed a flaccid blister containing serosanguineous fluid beside the areola of the right breast and small&#44; round&#44; pearly white macules on the right hemithorax and the outer quadrants of the right breast &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The patient presented no associated genital lesions&#46; In light of the suspected diagnosis of lichen sclerosus secondary to radiotherapy&#44; we performed a biopsy of the site of the blister&#46; Histopathology revealed epidermal atrophy and marked dermal hyalinization associated with superficial edema&#44; compatible with lichen sclerosus &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#46; Secondary subepithelial vesiculation&#44; responsible for the blister&#44; was also observed &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#46; Treatment was started with daily application of 0&#46;1&#37; topical tacrolimus&#44; which attenuated the whiteish macules and resolved the blister completely&#46; No subsequent new lesions appeared&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The exact prevalence of lichen sclerosus is unknown&#46; It is markedly more frequent in females and may appear at any age&#44; although peak incidence occurs around the fifth and sixth decades of life&#46; Genital involvement is most frequent &#40;85&#37; of cases&#41;&#44; concomitant extragenital involvement can be found in up to 20&#37; of cases&#44; and exclusively extragenital involvement is found in up to 2&#46;5&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The etiology is unknown&#44; although there appears to be some genetic predisposition&#46; A link with underlying autoimmune mechanisms has also been postulated&#44; as cases have been reported in association with diseases such as vitiligo&#44; alopecia areata&#44; and thyroiditis&#46; What is clear is the presence of the Koebner response in this disease&#46; Cases of lichen sclerosus have been reported in association with jellyfish stings&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> subcutaneous insulin injections&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> and chronic pressure sores&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> The Koebner response may explain the appearance of lesions in previously irradiated areas&#44; as in our case&#46; Although radiotherapy is currently widely used&#44; only 4 cases of lichen sclerosus induced by radiotherapy have been described in the literature &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">6&#8211;8</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Extragenital lichen sclerosus is generally asymptomatic&#44; although it may present with associated dryness and pruritus&#46; It most frequently affects the torso&#44; neck&#44; upper limbs&#44; and flexor surface of the wrists&#46; Lesions initially present as ivory-colored interfollicular polygonal papules that coalesce to form scleroatrophic plaques&#46; Telangiectasia and follicular plugging may be observed in more advanced stages&#46; Hemorrhagic blisters may appear owing to the fragility of the dermal-epidermal junction&#44; as in our case&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Diagnosis is essentially based on histologic findings&#44; which show a specific pattern characterized by sclerosis or uniform hyalinization of the superficial dermis&#44; and a lymphohistiocytic inflammatory infiltrate in an underlying band&#46; Other more variable findings include thinning and atrophy of the epidermis&#44; orthokeratotic hyperkeratosis&#44; vacuolar degeneration of the basal layer&#44; and dermal edema&#46; Loss of elastic fibers is frequent in this disease&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Genital lichen sclerosus only requires treatment in the event of associated pruritus or severe sclerosis&#46; The most commonly used treatments are potent topical corticosteroids and topical calcineurin inhibitors&#46; Systemic treatment is generally unnecessary in extragenital lichen sclerosus&#44; as it is a benign skin disease that&#44; unlike genital lichen sclerosus&#44; presents a low risk of malignant transformation of the lesions&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">We report a new case for the literature of lichen sclerosus induced by radiotherapy&#46; Although only 4 reported cases of the disease exist in the literature&#44; it is an entity we should be aware of given the current widespread use of radiotherapy&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Bonfill-Ort&#237; M&#44; Mart&#237;nez-Molina L&#44; Pen&#237;n RM&#44; Marcoval J&#46; Liquen escleroso extragenital inducido por radioterapia&#46; Actas Dermosifiliogr&#46; 2019&#59;110&#58;69&#8211;71&#46;</p>"
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Type of Tumor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Treatment Received&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Latency Period&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Location of Lichen Sclerosus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Yates et al&#46; &#40;1985&#41;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neoplasm of right breast&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Right breast&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Yates et al&#46;<br>&#40;1985&#41;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neoplasm of right breast&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Surgery<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>radiation therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9 y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Right breast&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Vujovic<br>&#40;2010&#41;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neoplasm of left breast&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Surgery<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>radiation therapy<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>hormone therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Left breast&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Edwards et al&#46;<br>&#40;2017&#41;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vaginal squamous cell carcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">External radiotherapy and brachytherapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16 mo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vulvar region&nbsp;\t\t\t\t\t\t\n
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Case and Research Letters
Extragenital Lichen Sclerosus Induced by Radiotherapy
Liquen escleroso extragenital inducido por radioterapia
M. Bonfill-Ortía,
Autor para correspondencia
mbonfill@hotmail.com

Corresponding author.
, L. Martínez-Molinaa, R.M. Penínb, J. Marcovala
a Servicio de Dermatología, Hospital Universitari de Bellvitge, Barcelona, Spain
b Servicio de Anatomía patológica, Hospital Universitari de Bellvitge, Barcelona, Spain
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The physical examination revealed a flaccid blister containing serosanguineous fluid beside the areola of the right breast and small&#44; round&#44; pearly white macules on the right hemithorax and the outer quadrants of the right breast &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The patient presented no associated genital lesions&#46; In light of the suspected diagnosis of lichen sclerosus secondary to radiotherapy&#44; we performed a biopsy of the site of the blister&#46; Histopathology revealed epidermal atrophy and marked dermal hyalinization associated with superficial edema&#44; compatible with lichen sclerosus &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#46; Secondary subepithelial vesiculation&#44; responsible for the blister&#44; was also observed &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#46; Treatment was started with daily application of 0&#46;1&#37; topical tacrolimus&#44; which attenuated the whiteish macules and resolved the blister completely&#46; No subsequent new lesions appeared&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The exact prevalence of lichen sclerosus is unknown&#46; It is markedly more frequent in females and may appear at any age&#44; although peak incidence occurs around the fifth and sixth decades of life&#46; Genital involvement is most frequent &#40;85&#37; of cases&#41;&#44; concomitant extragenital involvement can be found in up to 20&#37; of cases&#44; and exclusively extragenital involvement is found in up to 2&#46;5&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The etiology is unknown&#44; although there appears to be some genetic predisposition&#46; A link with underlying autoimmune mechanisms has also been postulated&#44; as cases have been reported in association with diseases such as vitiligo&#44; alopecia areata&#44; and thyroiditis&#46; What is clear is the presence of the Koebner response in this disease&#46; Cases of lichen sclerosus have been reported in association with jellyfish stings&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> subcutaneous insulin injections&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> and chronic pressure sores&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> The Koebner response may explain the appearance of lesions in previously irradiated areas&#44; as in our case&#46; Although radiotherapy is currently widely used&#44; only 4 cases of lichen sclerosus induced by radiotherapy have been described in the literature &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">6&#8211;8</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Extragenital lichen sclerosus is generally asymptomatic&#44; although it may present with associated dryness and pruritus&#46; It most frequently affects the torso&#44; neck&#44; upper limbs&#44; and flexor surface of the wrists&#46; Lesions initially present as ivory-colored interfollicular polygonal papules that coalesce to form scleroatrophic plaques&#46; Telangiectasia and follicular plugging may be observed in more advanced stages&#46; Hemorrhagic blisters may appear owing to the fragility of the dermal-epidermal junction&#44; as in our case&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Diagnosis is essentially based on histologic findings&#44; which show a specific pattern characterized by sclerosis or uniform hyalinization of the superficial dermis&#44; and a lymphohistiocytic inflammatory infiltrate in an underlying band&#46; Other more variable findings include thinning and atrophy of the epidermis&#44; orthokeratotic hyperkeratosis&#44; vacuolar degeneration of the basal layer&#44; and dermal edema&#46; Loss of elastic fibers is frequent in this disease&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Genital lichen sclerosus only requires treatment in the event of associated pruritus or severe sclerosis&#46; The most commonly used treatments are potent topical corticosteroids and topical calcineurin inhibitors&#46; Systemic treatment is generally unnecessary in extragenital lichen sclerosus&#44; as it is a benign skin disease that&#44; unlike genital lichen sclerosus&#44; presents a low risk of malignant transformation of the lesions&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">We report a new case for the literature of lichen sclerosus induced by radiotherapy&#46; Although only 4 reported cases of the disease exist in the literature&#44; it is an entity we should be aware of given the current widespread use of radiotherapy&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Type of Tumor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Treatment Received&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Latency Period&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Location of Lichen Sclerosus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Yates et al&#46; &#40;1985&#41;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neoplasm of right breast&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Surgery<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>radiation therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Right breast&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Yates et al&#46;<br>&#40;1985&#41;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neoplasm of right breast&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Surgery<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>radiation therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9 y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Right breast&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Vujovic<br>&#40;2010&#41;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neoplasm of left breast&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Surgery<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>radiation therapy<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>hormone therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Left breast&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Edwards et al&#46;<br>&#40;2017&#41;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vaginal squamous cell carcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">External radiotherapy and brachytherapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16 mo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vulvar region&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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