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SHORT COMMUNICATION
Year : 2022  |  Volume : 67  |  Issue : 5  |  Page : 531-534
Cross-sectional study shows an association between paediatric lichen planus and dyslipidemia


Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication29-Dec-2022

Correspondence Address:
Rahul Mahajan
Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijd.ijd_100_22

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   Abstract 


Background: Few studies have shown an association between adult lichen planus and dyslipidemia, but none has shown an association with the pediatric population. We planned to study the association between pediatric lichen planus and metabolic syndrome (MS). Methodology: This is a single-centre, cross-sectional, case-control study from July 2018 to December 2019 at a tertiary care institute. Twenty children in the age group of 6–16 years, diagnosed as cases of childhood/adolescent lichen planus, and 40 age- and sex-matched controls were included in this study and evaluated for metabolic syndrome. Patients' anthropometry including weight, height, waist circumference, and body mass index (BMI) was recorded. Blood samples were sent for the measurement of fasting plasma glucose, high-density lipoprotein (HDL), low-density lipoprotein (LDL) cholesterol, and triglyceride levels. Results: The mean HDL was found to be significantly lower in children with lichen planus compared to children without lichen planus (p = 0.012), although there was no statistically significant difference in the frequency of patients having deranged HDL levels between the groups (p = 0.326). Children with lichen planus had a higher prevalence of central obesity, but the difference was not statistically significant (p = 0.101). There was no significant difference between mean BMI, hypertension, triglyceride, LDL, and fasting blood sugar values between the groups. Using the logistic regression analysis model, it was found that the strongest independent variable that impacts the occurrence of lichen planus was an HDL value less than 40 mg/dl (p = 0.017; OR 1.02 to 1.29). Conclusions and Relevance: This study shows an association between paediatric lichen planus and dyslipidemia.


Keywords: Metabolic syndrome, lichen planus, paediatric


How to cite this article:
Mahajan R, Raj D, De D, Handa S. Cross-sectional study shows an association between paediatric lichen planus and dyslipidemia. Indian J Dermatol 2022;67:531-4

How to cite this URL:
Mahajan R, Raj D, De D, Handa S. Cross-sectional study shows an association between paediatric lichen planus and dyslipidemia. Indian J Dermatol [serial online] 2022 [cited 2023 Feb 8];67:531-4. Available from: https://www.e-ijd.org/text.asp?2022/67/5/531/366083





   Introduction Top


Lichen planus (LP) is an inflammatory disorder that affects all the appendages – the skin, hair, nail, and mucosa, which can be involved either concomitantly or sequentially.[1] LP is less common but more severe in children than in adults.[2] LP may serve as an external indicator of underlying immune and metabolic dysfunction.[3],[4] There are a few studies which show the association of metabolic syndrome (MS) and dyslipidemia with LP in adults.[5],[6] However, such literature studies are lacking in childhood lichen planus. Hence, we planned to study the association between pediatric LP and metabolic syndrome and/or its individual components.


   Materials and Methods Top


This was a single-centre, cross-sectional study conducted at the Paediatric Dermatology clinic of a tertiary care institute from July 2018 to December 2019 after appropriate permission from the Institute's Ethics Committee. Consecutive paediatric patients of lichen planus were included. As a pilot study, a convenient sample size of 20 patients and 40 controls was decided. Twenty consecutive children and adolescents were screened for eligibility; children of either gender in the age group of 6–16 years, diagnosed as cases of childhood/adolescent LP by at least two dermatologists, were included. Forty apparently healthy unrelated children in the same age group without personal or family history lichen planus were recruited as controls. Disorders such as atopic eczema, psoriasis, pediatric acne, and acanthosis nigricans were excluded.

The thorough clinical history and family history of type 2 DM, dyslipidemia, cardio-vascular disease (CVD), hypertension (HTN), and obesity in first-degree relatives along with treatment history were recorded. Clinical examination of the cases included general physical examination, blood pressure (BP) measurements, and muco-cutaneous examination for LP. Hypertension was defined as per the 2017 American Academy of Paediatrics (AAP) guidelines for childhood hypertension.[7] Each patient was given an age-, gender-, and height-specific BP percentile as per the charts devised by Raj et al.[8] for Indian children. Subjects were evaluated for the presence of obesity/MS using International Diabetes Foundation (IDF) definition of MS in children and adolescents.[9]

Anthropometry included weight and height measurements and body mass index (BMI) calculations. Age- and gender-specific BMI percentiles were assigned to each subject using the 2015 Indian Academy of Paediatrics (IAP) revised growth charts for 5–18-year-old Indian children.[10] Children with BMI values ≥23 adult equivalents were classified as over-weight, and those with values ≥27 adult equivalents were classified as obese. Waist circumference (WC) was measured in centimetres mid-way between the most inferior rib and the superior border of the iliac crest with an inelastic measuring tape. The age- and sex-specific WC percentile curves developed by Khadilkar et al.[11] for Indian children (2–18 years old) were taken as reference. Laboratory analysis included the measurement of fasting plasma glucose, high-density lipoprotein (HDL), low-density lipoprotein (LDL) cholesterol, and triglyceride levels.

Statistical analysis

For a pilot study, a convenient sample size of 20 patients and 40 controls was taken. Group comparisons were made with the Chi-square test/Fisher's exact test. Continuous data were given as mean ± SD and range or median and inter-quartile range, as appropriate. Normalities of quantitative data were checked by measures of Kolmogorov–Smirnov tests of normality. For skewed data, comparisons for two groups were made by Mann–Whitney test. For normally distributed data, Student's t-test was applied to compare the two groups. To find independent predictor for lichen planus, logistic regression analysis (LRA) was carried out. A P value < 0.05 was considered significant. Analysis was conducted using IBM SPSS STATISTICS (version 22.0).


   Results Top


[Table 1] summarises the baseline demographic characteristics of the study population. When tested for normality, data pertaining to the parameters such as age, HDL, LDL, triglyceride (TG), fasting blood sugar (FBS), BMI, and systolic and diastolic BP were found to be normally distributed and hence presented as mean ± SD. Both cases and controls were matched with respect to the age and gender. The mean age at onset of lichen planus in children was 9.9 ± 2.77 years, and the median duration of the disease was 16.9 months. The papular type of morphology was the most frequent presentation (45%), followed by mixed morphology (20%).
Table 1: Baseline demographic characteristics of cases and controls

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Children with lichen planus had a higher prevalence of central obesity, but the difference was not statistically significant (35% among cases compared to 15% among controls, P = 0.101). Although there was no statistically significant difference in the frequency of patients having deranged HDL levels between the groups (30% among cases vs 17.5% among controls with (weighted mean difference 5.15, 95% CI 9.13 to -1.16, P = 0.326) yet, the mean HDL was found to be significantly lower in children with lichen planus compared to children without LP (43.5 ± 7 mg/dl in cases vs 48.7 ± 7.39 mg/dl in controls, P = 0.012). Children with LP aged ≤10 years had higher prevalence of WC, FBS, HDL, and TG when compared to children less than 10 years of age with LP, but the difference was not statistically significant. Using the logistic regression analysis model, it was found that the strongest independent variable that impacts the occurrence of lichen planus was an HDL value less than 40 mg/dl (p = 0.017; OR 1.02 to 1.29) [Table 2] and [Table 3].
Table 2: Comparing anthropometric and laboratory parameters between cases and controls

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Table 3: Multi-variate regression analysis of variables

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   Discussion Top


Lichen planus is a chronic, relapsing, and remitting skin condition with complex pathogenetic mechanisms. Various studies have highlighted the association of adult lichen planus with conditions such as obesity, diabetes, hypertension, and dyslipidemia. Chronic inflammation, elevated levels of C-reactive protein, and T-helper cell hyper-activity with cytokine (TNF-α, IL-6) release are some of the suggested mechanisms to explain association.[5] The present study also observed a male predominance in childhood LP with a papular morphology being the most common sub-type, similar to the previous studies from our centre.[12] Nail changes of lichen planus were seen in 10% of the patients, which is almost equal to that of a study conducted by Luis-Montaya et al.[13]

We observed that the prevalence of MS in children and adolescents with lichen planus was 5%, which was more when compared to healthy children (2.9%) but not statistically significantly different. Because there were no data on pediatric LP on this topic, we compared our findings with another chronic skin disease, that is, pediatric psoriasis. These findings are similar to observations in a recent meta-analysis where the prevalence of MS was found to be significantly higher in patients with psoriasis compared to healthy controls [p < 0.001; OR = 6.10 (2.66 to 13.98)].[14]

Dyslipidemia predisposes to atherosclerosis which enhances the chances of unfavorable cardio-vascular events such as myocardial infarction, stroke, and peripheral vascular disease. In this study, children with lichen planus had a more atherogenic lipid profile compared to children without LP. The mean HDL values were also significantly lower in cases as compared to controls (p = 0.012). HDL cholesterol has an anti-atherogenic role as it accepts cholesterol from lipid-laden macrophages, such as those within atherosclerotic plaques, for transport and eventual biliary excretion. In a recent meta-analysis, Lai et al.[15] found that adult onset LP was associated with significantly higher levels of triglycerides (p = 0.048). Using the logistic regression analysis model, we found that the strongest independent variable that impacts the occurrence of lichen planus was an HDL value less than 40 mg/dl. Thus, we infer that lichen planus is a condition with persistent low-grade inflammation that predisposes to development of an atherogenic profile early in the course of the disease. This may further enhance the risk of other co-morbid conditions such as obesity, HTN, and future cardio-metabolic adverse events as the children grow into adolescence and adulthood.

Concluding this study shows a positive relation between childhood lichen planus and dyslipidemia. Early and systematic screening of children with lichen planus for these co-morbidities and appropriate counselling of parents thus become the responsibility of the treating dermatologist.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Boyd A, Neldner K. Lichen planus J Am Acad Dermatol 1991;25:593-619.  Back to cited text no. 1
    
2.
Nanda A, Al-Ajmi H, Al-Sabah H. Childhood lichen planus: A report of 23 cases. Pediatr Dermatol 2001;18:1-4.  Back to cited text no. 2
    
3.
Gorouhi F, Davari P, Fazel N. Cutaneous and mucosal lichen planus: A comprehensive review of clinical subtypes, risk factors, diagnosis, and prognosis. Scientific World Journal 2014;2014:742826.  Back to cited text no. 3
    
4.
Reaven GM. Banting lecture 1988. Role of insulin resistance in human disease. Diabetes 1988;37:1595-607.  Back to cited text no. 4
    
5.
Krishnamoorthy B, Gn S, N SM, M BS, Garlapati K. Lipid profile and metabolic syndrome status in patients with oral lichen planus, oral lichenoid reaction and healthy individuals attending a dental college in northern India-A descriptive study. J Clin Diagn Res 2014;8:92-5.  Back to cited text no. 5
    
6.
Dreiher J, Shapiro J, Cohen AD. Lichen planus and dyslipidaemia: A case-control study. Br J Dermatol 2009;161:626-9.  Back to cited text no. 6
    
7.
Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics 2017;140:e20171904.  Back to cited text no. 7
    
8.
Raj M, Sundaram R, Paul M, Kumar K. Blood pressure distribution in Indian children. Indian Pediatr 2010;47:477-85.  Back to cited text no. 8
    
9.
Zimmet P, Alberti KG, Kaufman F, Tajima N, Silink M, Arslanian S, et al. The metabolic syndrome in children and adolescents-an IDF consensus report. Pediatr Diabetes 2007;8:299-306.  Back to cited text no. 9
    
10.
Khadilkar VV, Khadilkar AV. Revised Indian Academy of Pediatrics 2015 growth charts for height, weight and body mass index for 5-18-year-old Indian children. Indian J Endocrinol Metab 2015;19:470-6.  Back to cited text no. 10
    
11.
Khadilkar A, Ekbote V, Chiplonkar S, Khadilkar V, Kajale N, Kulkarni S, et al. Waist circumference percentiles in 2-18 year old Indian children. J Pediatr 2014;164:1358-62.e2.  Back to cited text no. 11
    
12.
Kanwar A, De D. Lichen planus in childhood: Report of 100 cases. Clin Exp Dermatol 2010;35:257-62.  Back to cited text no. 12
    
13.
Luis-Montoya P, Domínguez-Soto L, Vega-Memije E. Lichen planus in 24 children with review of the literature. Pediatr Dermatol 2005;22:295-8.  Back to cited text no. 13
    
14.
Pietrzak A, Grywalska E, Walankiewicz M, Lotti T, Roliński J, Myśliński W, et al. Psoriasis and metabolic syndrome in children: Current data. Clin Exp Dermatol 2017;42:131-6.  Back to cited text no. 14
    
15.
Lai YC, Yew YW, Schwartz RA. Lichen planus and dyslipidemia: A systematic review and meta-analysis of observational studies. Int J Dermatol 2016;55:e295-304.  Back to cited text no. 15
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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