Lower Extremity Venous Ablation as a Treatment Modality for Refractory Lichen Simplex Chronicus and Generalized Pruritus

Introduction: Lichen simplex chronicus (LSC) is a skin condition characterized by thick, leathery, scaly and extremely itchy patches of skin. It is a common pathology (up to 12% of population) with signifi cant effect on quality of life without any established clear etiology or treatment. Chronic venous insuffi ciency (CVI) is a progressive disease of the legs that occurs when the delicate bicuspid valves in the veins become weakened and develop refl ux. CVI has been associated with many complications including local or generalized pruritus that may lead to intractable itch-scratch cycle, leading to LSC lesions on various parts of the body. Cases: Recent development of multiple in-offi ce ablation techniques for treatment of CVI have led to the added benefi t of resolving the itch-scratch cycle, which in turn become the cure for LSC lesions. We present 6 cases with typical refractory LSC lesions whom we were able to cure after treatment of CVI using Radiofrequency ablation or Clarivein techniques. Conclusion: We recommend all primary care physicians and dermatologists to consider an underlying CVI as a potential cause for any LSC lesions or even intractable pruritus. Case Report Lower Extremity Venous Ablation as a Treatment Modality for Refractory Lichen Simplex Chronicus and Generalized Pruritus Robert Wills DO, James Kleist, Hossein Akhondi* and Sassan Kaveh Internal Medicine Residency Department and Alpha Medical group Mountain View Hospital Center, Las Vegas, NV, USA Received: 15 October, 2018 Accepted: 02 November, 2018 Published: 03 November, 2018 *Corresponding author: Hossein Akhondi, MD FACP, Associate Program Director, 2880 N. Tenaya Way, Suite 100 Las Vegas, NV 89128, Tel: (702) 281-7243; E-mail: H68akhond@hotmail.com


Introduction
Lichen simplex chronicus (LSC) is essentially lichenifi ed skin caused by repeated rubbing or scratching. Chronic scratching causes further itching through several mechanisms, creating a vicious cycle. LSC is commonly diagnosed by clinical presentation: thickened, leathery, scaly, hyperpigmented and excoriated. LSC lesions can involve any part of the body but typically starts in the medial aspects of the distal legs before spreading to the other parts. The itch usually starts in the evenings, but scratching happens in the middle of sleep and then progresses to a constant intractable itch that can very negatively impact quality of life.
The underlying etiology of LSC has been attributed to pruritic sequela of focal trauma. This lack of understanding and objective rational for the itch has led to the neurotic behavior hypotheses which implies anxiety and obsessivecompulsive disorder as the underlying cause. Hence the term Neurodermatitis is often used.
Treatment is commonly focused on relieving pruritus and skin manifestations, with the perception that LSC is a primary skin condition. Treatment recommendations vary from topical corticosteroids, injected corticosteroids, topical calcineurin inhibitors, antihistamines, gabapentin, Ultra Violate B, colloid baths, coal tar and behavioral modifi cations.
Chronic venous insuffi ciency (CVI) is a systemic disease that can have grave skin manifestations. These include not only LSC lesions but also stasis dermatitis and venous stasis ulcers. CVI can increase hydrostatic pressure, causing skin compromise and progression to local reaction due to release of infl ammatory mediators. Other non-dermatological symptoms of CVI include leg ache, refractory edema, muscle cramps and restless legs. Physicians have recently been more aware of these non-dermatological symptoms of CVI, but the dermatological complications remain very unrecognized.

Cases and Methods
Six patients aging 33 to 84 years old with symptomatic chronic venous insuffi ciency (CVI) were referred to Alpha Vein Clinic in Las Vegas. Patients were found to also have overlain refractory LSC that were affecting their quality of life While the pathophysiology of LSC is attributed to a secondary reaction from the itch-scratch cycle and the subsequent local infl ammatory reaction, the primary etiology has not been clearly elucidated in the literature [1,2]. Some authors currently claim a relationship between underlying psychiatric    pathology and a predilection to compulsively scratch as seen in cross-sectional [3], retrospective cohort [4], and case-control [5] studies. Recent studies postulate a correlation between LSC and peripheral neuropathy [4,6]. Increased frequency of degenerative spine conditions on MRI and radiculopathy on electrophysiological studies were observed in LSC patients compared to public. Case reports exist for instigation of LSC from herpes zoster [7], atopic dermatitis from hair dye [8], and nocturnal scratching [9]. A review of PubMed yielded zero results for LSC correlation with chronic venous insuffi ciency.
Chronic venous insuffi ciency most commonly presents with pruritus, with additional fi ndings of leg heaviness and tightness according to the Bonn Vein study of 2,624 subjects [10]. Pruritus was not associated with age, gender, body mass index or region of living, with 95% confi dence interval crossing one for all subsets. Stasis dermatitis which is a similar clinical entity has demonstrable correlation with venous insuffi ciency [11] as well. Recent histologic studies indicate utility of Gomori iron studies to differentiate stasis dermatitis from LSC, in addition to other common dermatoses, based on degree of iron staining [12].
Treatment for LSC remains controversial. Topical glucocorticoids remain a common initial treatment to reduce scratching [13]. Double-blind, multicenter, head-to-head trials of topical corticosteroids have been pursued in small study samples, with higher treatment success and quicker healing rates of halobetasol propionate ointment compared to difl ucortolone valerate [14]. Case reports of treatment with gabapentin, topical tacrolimus, alitretinoin, and UVB exist and require confi rmation but overall this has been an extremely hard to treat disease.
Our focus in vein clinic has been to address the CVI but somewhat accidently we noted the therapeutic effect on LSC.
This was repeated in another 5 cases, as described. In one case, both upper and lower extremity severe pruritus and LSC resolved after lower extremity venous ablation. This can probably be a causal relationship explained by resolving circulating histamines in the entire body while treating the local CVI. All the cases were CEAP classifi cation C4 a/b with no ulceration present and there might be a possibility that this category specifi cally brings the patients in (less symptoms with lower categories) and that our treatments overlap with it.
This incidental fi nding could provide a modality of therapy for a traditionally hard to treat entity with excellent success rate.

Conclusion
With the likely attribution of disseminated LSC lesions to local infl ammatory mediators from CVI, we suggest an evaluation for venous vascular insuffi ciency for curative endovascular venous ablation in all patients with LSC. Further prospective randomized trials are recommended to further evaluate this.