Lichen Planus Flashcards
What is lichen planus
Chronic condition, intermittent, affecting those 30-50 years old,
In skin cases- 50% causing oral lesions
In oral cases- 10-30 % skin lesions
Can be drug related or idiopathic (most often)
Clinical presentations of lichen planus
Reticular-lacy patter of white lines running around mucosa
Atopic/erosive- erythematous or no mucosa. Yellowish fibrinous covering over the base of connective tissue
Ulcerative- extensive, symptoms vary (some no or little symptoms as fibrinous covering protects them).
We should treat the symptoms- which are the core for patients management and lesions itself cannot be cured by any intervention
What is lichen planus-hostologically
Clear and classical T- cell infiltrate into the basement membrane area of connective tissue.
Lymphocytic band over basement membrane is the key diagnostic feature of lichen planus.
Other findings: saw-tooth rete ridges, basal cell damage, patchy acanthosis and parakeratosis of the superficial epithelium l; dead keratinocytes in epithelium -called Civatte bodies
What histological changes tell us about lichen planus
It causes lymphocyte activation in an attempt to remove chronic irritation
Can be overreaching to ‘normal’ triggers
Can be due to external triggers such as medicines or amalgam restorations…
Most likely it is Langerhans cells in the epithelium are presenting an antigen which is activation immune response and the attempt of the immune response to remove this chronic irritation is what causes the changes in the epithelium and the clinical appearance
Lichen planus does not have a single cause
Other possible causes of lichen planus
Genetic predisposition
Physical and emotional stresses
Injury to the skin
Systemic viral infections (hep C…)
Contact allergy
Drugs (gold, Beta-blockers ACE inhibitors….)
Cutaneous lichen planus
Occurs in many forms
Usually around the wrists-raised purple lesions with white surface with striae- Wickham’s striae-
Can be really itchy and usually a trauma on this area is from scratching
If affects the scalp-areas of hair loss in affected spots
In nails-ridging
Symptoms of lichen planus
Usually none
May be relative to thinning epithelium due to atrophic changes - sensitive to hot/spicy food
Burning sensation in the mucosa
oral lichen planus sotes
Most often buccal mucosa
Gingivae, tongue(idiopathic, due to loss of papillae and smooth tongue surface), lips, palate
Contributing factors to LP
Idiopathic
Medication
Amalgam restorations
If cause if known- referred as lichenoid response to…..
Common medication associated with LP
ACE inhibitors
Beta-adrengeric blockers
Diuretics
NSAIDs
Gold
Penicillamine
Lichenoid drug reaction
More often widespread lesions
Offer bilateral and mirrored
Often poorly responsive to standard steroid treatment
Management of lichenoid drug reaction
We have to consider the benefit of the drug and if it outweighs the side effects (does the benefit of stopping the drug outweigh the risk to the patient health; if significant lichen symptoms (where maximum topical or systemic treatment is needed to control the lichen symptoms) - probably we will look into stopping the drug
Risk of stopping the drug
Discomfort from symptoms and how much treatment is needed for lichenoid reaction as a result of the drug
Always talk to GP to see if there is a alternative drug
Amalgam related LP
Lesions is usually in close proximity to the amalgam restoration (usually old amalgam rather than newly placed amalgam restoration)
Not clear why LP happens when mucosa is in contact with amalgam or mercury
Patch test can be done but not clear if that is useful
Usually restoration is removed and replaced with different material-if sensible and practical to do so (replacing means more tissue removed, cost to the pt)-should only be changed if in direct contact to lichenoid lesion. Replaced by composite usually or gold, or bonded crowns
Lesions can be removed as LP have potential to become malignant
Removal of amalgam- use of rubber dam, high volume suction, PPI; avoided during pregnancy
LP management
- Removal of disease- medicines or dental restorations
- Biopsy- unless a good reason not to do so (if not cleared if it is LP- do biopsy!)
- Blood tests- haematinic tests, FBC, if suspecting lupus- ANA, Ro..
Management/medication for mild intermittent LP lesions
Topical over the counter medication - chlorhexidine or benzdamine mouthwash
Avoidance of SLS containing toothpaste- driver in many cases especially if gingival lesions present
Management/medication for persisting symptomatic LP lesions
In primary care- topical steroids (same as for ulcers)- Beclomethasone MDI (0.5 mg/puff, 2 puffs x 2-3 daily) and Betamethasone rinse ( 1 mg/10ml/2 min/2daily
If those not working go for:
Topical tacrolimus; hydroxyxhloroquine, systemic immunomodulators
Gingival LP- management
Gingival veneer (vacuum formed device) can be made and steroid cream can be inserted in the tray and hold it in place so it is in contact with the lesion for a longer period of time
Lesions similar to LP
Can be in pt that had bone marrow transplant where graft versus host disease happens- Similar lesions
Lupus erythematous can also cause similar lesion- but usually on palate, it is solitary lesion in oral mucosa and is associated with systemic autoantibodies. Histological differs from LP as lymphocytic infiltrate is much deeper in CT and away from the basement membrane. If lesions are in mouth and elsewhere - think lupus, if only orally - not lupus!)
Intraoral site most common for incidental finding of oral lichen planus
Buccal mucosa
Which site is less commonly affected by oral lichen planus
Palate
Which connective tissue disease may present as lichen-like lesions involving the palate?
Lupus erythematous
In lupus- subepithelial lymphocytic infiltrate can spread much deeper into the tissue and may not be confined to the band-like distribution typical of lichen planus
What skin site can be typically affected by LP in addition to wrist/dorsum of hands?
Shins and scalp
Name one extra oral structure/site (in addition to skin) that is often involved with LP
Genital mucosa
Hair
Nails
LP is a chronic condition of serous and mucus membranes
Eye involvement has been reported -but very rare
Cell damage within the basal layer of the stratified epithelium is a typical feature of LP. Name two cytological features indicative of this level of cell damage
Civatte bodies
Necrotic keratinocytes
Vacuolar changes
Oral LP is an idiopathic chronic inflammatory condition of the skin and mucous membranes but a number of factors have been implicated in the modulation of immune responses. Which virus has been implicated in the up-regulation of immune responses of LP?
Hepatitis C virus
Antihypertensive drugs are amongst the drugs most commonly associated with drug-induced lichenoid reactions. Which other drugs are commonly associated with lichenoid reactions?
ACE inhibitors
Beta-blockers
Diuretics
Calcium channel blockers are not- most common side effect of them is gingival overgrowth
Drug induced oral lichenoid reactions can be relatively severe and sometimes poorly responsive to standard treatment of oral LP. Discontinuation of the implicated drug may be considered in some scenarios. Within which time frame should you expect the lichenoid lesions to heal on discontinuation of the drug?
2-6 months
Differential diagnosis of white spiderweb lesions, asymptomatic (pt on hypertension medication)
Leukoedema (normal variation of buccal mucosa, ofter associated with smoking, usually symetrical opaque/gray/white diffuse patches; opaque changes usually disappear with stretching the buccal mucosa, no treatment only reassurance)
Lichen planus ( bilateral symetrical reticular pattern of fine white lines bilaterally on the buccal mucosa, skin lesions ( violet, itchy, raised) may be associated as well as genital lesions)
White sponge naevus- rare inherited condition which causes diffuse keratosis or multiple discrete white patches on any mucosa, including oral and genital mucosa, family history can confirm diagnosis but can be spontaneous mutation)
Chronic hyperplastic candidosis( arises mostly on buccal mucosa on labial commissure, lesions have speckled appearance, more common in smokers and pt with diabetes)
Frictional keratosis (common across occlusal line on the check, known as “linea alba”, associated with cheek biting or bruxism; can show symptoms/signs of tooth sensitivity or tooth wear)
The predominant cells on sub-epithelial band in LP are:
Macrophages
Lymphocytes
What is the name of the presence of inflammatory cells amongst the deeper keratinocytes?
Epitheliortopism
The disturbance in the deeper epithelial layers of the basal cell layer, with vacuolation of some of the basal cells is calledM
Liquefaction degeneration of the basal cell layer
Some cells have distinct eosinophilic cytoplasm and very dark staining nuclear remnants which may be fragmented. They look like there is a clear halo around them? What process are they going through?
Aproptosis
What is Koebner phenomenon?
Development of skin lesions secondary to a trauma or irritation. Can happen in LP or psoriasis
Reticular lichen planus
Classic pattern and the buccal mucosa is the typical site, can be seen on tongue
Presents as a largely asymptomatic network of white interlacing keratotic striae
Usually bilateral and symetrical
Desquamative gingivitis-gingival LP
On labial or buccal gingivae
Red and glazed
Pt report discomfort when eating spicy foods or acidic drinks; burning sensation of the gingivae
Poor OH can exaggerate the erythema and symptoms
This can happen in pt with Pemphigus and mucous membrane pemphigoid
Atophic LP
Shallow atrophic,, erythematous areas occasionally surrounded by white striae or plaques
Associated commonly with pain or discomfort
May mimic erythroplakia
Papular LP
Presents as small white raised areas approximately 1-2 mm in diameter
The typical site is buccal mucosa and dorsum of the tongue
Bullous LP
Rare
Can present as intraoral blisters on the mucosa
Result of intensive liquefaction degeneration of the basal cell layer leading to formation of bullae
Erosive LP
Very painful
White spread areas.of erosion on oral mucosa
Plaque like LP
Appears as a confluent white patch, especially on the dorsum of the tongue, that can mimic other types of leukoplakia
Need biopsy for diagnosis
There can be scarring/pigmentation in LP- how does pigmentation happen?
Pigmentation results from melanin incontinence in basal cell layer
Malignant change in oral LP
LP may undergo malignant transformation, especially erosive, atrophic and gingival forms
Studies show that 1% may undergo malignant transformation over 10 years
Lichenoid tissue reactions (LTR)
Are discrete oral lesions that resemble LP and usually occur in response to local stimuli
Patch test can be done
Can be due to:
Amalgam
Mercury
Can often be resolved by removal of stimulus
Drugs can also cause LTR:
NSAIDs
Diuretics
Oral hypoglycemics
Antihypertensives (especially beta blockers)
