Levonorgestrel-releasing intrauterine system causes a lichenoid drug eruption.

To the Editor: Numerous drugs have been implicated as possible causes of lichenoid drug eruptions (LDEs). We describe a case of an LDE secondary to placement of a levonorgestrel-releasing intrauterine system (IUS). A 28-year-old woman presented with an extensive pruritic rash of 2 months’ duration. She reported that it began on the wrists; progressed inward to involve the trunk; and then became generalized over the trunk, back, wrists, and legs. A levonorgestrel-releasing IUS had been placed 6 weeks prior to the onset of the rash. She was otherwise healthy and took loratadine and pseudoephedrine on occasion for environmental allergies. On examination there were violaceous, lichenified, flat-topped, polygonal papules scattered over the arms, legs, and trunk (Figure 1). Some papules demonstrated a Köbner phenomenon. No Wickham striae or mucosal involvement was noted. Rapid plasma reagin and hepatitis panel were negative. The patient was treated empirically with fluocinonide ointment 0.05% twice daily. A shave biopsy was taken at the initial visit prior to steroid treatment. Histology revealed a classic lichenoid reaction pattern (Figure 2) and irregular acanthosis lying above the dense bandlike infiltrate of lymphocytes with liquefaction degeneration of the basal layer, rare Civatte bodies in the epidermis, and melanophages in the dermis. At 5-week follow-up, the patient showed some improvement but not complete control of the lesions with topical steroids. Because the patient was on no other regular medications, we recommended a 3-month trial removal of the IUS. The patient decided to have the IUS removed and noted complete clearance of the skin lesions within 1 month. Challenge with oral or intradermal levonorgestrel was not conducted after clearance of the rash, which is a weakness in this report. Accordingly, the possibility that this patient’s condition was caused by idiopathic lichen planus, which may resolve spontaneously, cannot be ruled out. However, because the patient noted substantial improvement following removal of the device and remained symptom free 2 years after removal, we concluded that the cutaneous lesions were secondary to an LDE in response to the IUS. It should be noted that as-needed use of pseudoephedrine and loratadine continued during this 2-year follow-up period and again the patient Dr. Jones is from the Department of Medicine, Harbor-UCLA Medical Center, Torrance. Dr. Shuler was from and Dr. Zlotoff is from the Department of Dermatology, University of New Mexico Health Science Center, Albuquerque. Dr. Shuler currently is from the University of South Carolina School of Medicine, Greenville. The authors report no conflict of interest. Correspondence: Barrett J. Zlotoff, MD, Department of Dermatology, University of New Mexico Health Science Center, 1021 Medical Arts Ave NE, Albuquerque, NM 87102 ([email protected]). Levonorgestrel-Releasing Intrauterine System Causes a Lichenoid Drug Eruption