Correspondence Address:
Dr. Mustafa Urun
Department of Dermatology, Faculty of Medicine, Trakya University, Edirne
Turkey

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Dear Editor,

Laugier–Hunziker syndrome (LHS) is a rare disorder characterized by acquired macular hyperpigmentation of the oral mucosa and the nails.[1] Different phenomena accompanying this syndrome are described in the literature: esophageal melanocytosis, actinic lichen planus, hypocellular marrow, thrombocytopenia, invasive melanoma, and lupus erythematosus.[2]

With this case, we present LHS that developed in a patient who had been diagnosed with palmoplantar psoriasis for 10 years.

A 55-year-old male patient presented with numerous brown, hyperpigmented, macular lesions with sharply demarcated borders on both palms and soles, the fingers, and the oral mucosa. The patient also had noticeable hyperkeratosis of both palms and soles, subungual hyperkeratosis of the fingers and toenails, and longitudinal melanonychia on the third nail of the right foot [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d, [Figure 1]e, [Figure 1]f. His medical history revealed that he had had palmoplantar psoriasis for 10 years and hyperpigmentation on the hands and feet for 2 years and on the lips for a few weeks. He had received various topical treatments periodically for palmoplantar psoriasis but had not received psoralen plus ultraviolet A treatment. Examinations of the genital and oral mucosa of the patient, who does not have a known chronic disease, a drug that he constantly uses, and does not smoke, were normal. In the accompanying gastrointestinal tract examination, no signs of bleeding, diarrhea, and malabsorption were detected. No other family member had similar lesions.{Figure 1}

The results of biochemical tests (liver and renal function tests and electrolytes), hemogram, hormonal tests, tumor markers, antinuclear antibody level, and HIV and syphilis serology tests were found to be normal. In the ultrasound of the entire abdomen with colonoscopy examination for malignancy screening, no pathological signs were found. The hyperkeratotic plaque, including the hyperpigmented macule on the patient's sole, and the hyperpigmented macule on the lips were examined histopathologically. Upon detection of suprapapillary thinning accompanied by hyperkeratosis, parakeratosis, and psoriasiform hyperplasia in the biopsy performed from the sole, the patient was histopathologically diagnosed with psoriasis [Figure 2]a. In addition, increased pigmentation in basal keratinocytes was consistent with hyperpigmented macules associated with LHS [Figure 2]b. The biopsy sample taken from the lip showed increased pigmentation in basal keratinocytes and an increase in melanophages in the papillary dermis [Figure 2]c and [Figure 2]d. Based on all the findings, the patient was diagnosed with LHS with palmoplantar psoriasis.{Figure 2}

LHS, whose etiology is not fully elucidated, is more common in white people and the average age of onset is 52 years.[2],[3] It has been shown that pigmentation in LHS is most often seen on the lower lip and the buccal mucosa. Other mucosal surfaces where similar lesions can be seen include conjunctiva, oropharynx, esophagus, vulva, anus, and perineum.[4] The extraoral involvement is most often observed in the form of longitudinal melanonychia on the nails.[1],[4] In addition, hyperpigmentation can be observed on the neck, chest, abdomen, and acral surfaces, especially on the fingertips.[3]

A diagnosis of LHS is made based on the age of the onset, the distribution of pigmentation, and the absence of pathological manifestations in colonoscopy, patient's personal medical history of cancer, and gastrointestinal tract symptoms.[3] In differential diagnosis, the causes of hyperpigmentation in appearance and etiologically should be reviewed individually. Drug-induced pigmentation, smoking, idiopathic melanoplakia, Addison's disease, and other syndromes such as Peutz–Jeghers syndrome, Bandler syndrome, and McCune–Albright syndrome must be investigated.[2],[3]

In the literature, when cases of LHS with psoriasis were reviewed, there was only one case with subacute cutaneous lupus erythematosus and psoriasis published by Kemmet et al. in 1990.[5] The case we present here, to our knowledge, is the first LHS case associated with palmoplantar psoriasis. LHS's relationship with other diseases is not entirely clear, and these conditions are considered coincidences.[2] However, it is also believed that this syndrome is more common than reported.[1]

In conclusion, it is important to know that LHS is a chronic but benign syndrome, asymptomatic pigmentation may increase gradually, and there is no effective treatment. Furthermore, distinguishing it from other malignant conditions will save the patient from invasive procedures. We believe that as more awareness develops about this syndrome, reporting of concomitant diseases will increase.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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