Case Report: Sequential multi-stage dermoscopic evolution of hypertrophic lichen planus in a patient with varicose veins.

Hypertrophic lichen planus (HLP) is a chronic, T-cell-mediated inflammatory dermatosis characterized by verrucous, hyperkeratotic papules and predominantly affecting the lower extremities. Dermoscopy has emerged as a valuable non-invasive tool for diagnosing HLP; however, sequential dermoscopic documentation spanning multiple evolutionary stages within a single patient has rarely been reported. Here, we describe a 62-year-old male who presented with progressively enlarging hyperkeratotic nodules on the right lower leg, notably concentrated on the side affected by varicose veins. Dermoscopic examination of lesions at different anatomical sites simultaneously revealed distinct sequential features corresponding to discrete stages of HLP evolution: (1) structureless pigmented areas with hairpin and dotted vessels; (2) diffuse pigmentation with emerging Wickham striae and keratinous plugs (corn pearls); (3) volcano crater-like morphology with elevated keratinous plugs and violaceous striae; and (4) fully developed "bouquet of white roses" pattern with lobulated hyperkeratotic masses. Skin biopsy confirmed the diagnosis with irregular epidermal hyperplasia, wedge-shaped hypergranulosis, and a dense band-like lymphocytic infiltrate. This case demonstrates the full dermoscopic spectrum of HLP across lesions at different stages in a single patient at one time point, and highlights the probable role of chronic venous insufficiency in promoting Koebner-like lesion development. Our findings may assist clinicians in the non-invasive diagnosis and staging of HLP.