Lichen Planus Flashcards
summary of lichen planus
chronic disease
mainly affecting age 30-50
skin cases 50% oral lesions
oral cases 10-30% skin lesions
can be idiopathic / drug related / systemic disease related
reticular lichen planus
lacy pattern of white lines across mucosa
atrophic / erosive lichen planus
background of erythematous change is atrophy of mucosa and where this is the predominant feature this is termed atrophic lichen planus
When there is no epithelium at all it is ulcerative / erosive lichen planus
Yellow fibrous covering over the base of the connective tissue
treat symptoms not appearance
what is lichen planus (histologically)
clear T cell infiltrate into basement membrane of connective tissue; this lymphocytic band hugging the basement membrane is a key diagnostic feature of lichen planus
can also see:
orthokeratosis
wedge shaped hyper granulosis
civatte bodies (dead keratinocytes)
dermal epidermal junction obscured by lymphocytes
vacuoles at basal layer
thick band of lymphocytes under epidermis
langerhans cells also involved
lichenoid reaction (histologically)
chronic inflammatory cell infiltrate
saw tooth rete ridges
basal cell damage
patchy acanthosis
parakeratosis
causes of LP
not caused by one single thing but rather a multitude of things being presented to the langerhans cells & this is the end pathway
- lymphocytic activation
- attempt to remove chronic irritation, overreaction to ‘normal’ triggers
- virus implicated in immune upregulation but NOT as a cause of LP i.e. hep C / herpes
- sometimes external triggers i.e. medicines, amalgam restorations
other causes thought to include:
genetic predisposition, physical / emotional stress, injury to skin, localised skin disease such as herpes zoster, systemic viral infection, contact allergy, drugs
symptoms
often none
may relate to thinning of epithelium so can be sensitive to hot/spicy food or having burning sensation in mucosa
up to 50% pt have other areas in body involved which can be before, during or after oral lesions i.e. skin, scalp, genital, hair, nails
oral LP sites
buccal mucosa
gingiva (desquamative gingivitis)
tongue - lateral aspect, dorsum
lips
palate
buccal LP
commonest site
anywhere on BM - anterior at commissure, mid, posterior around 3rd molar tooth
most common site for incidental finding & easy biopsy site
gingival LP
can be found in isolation often termed desquamative gingivitis
- similar clinical appearance to gingival pemphigoid and to plasma cell gingivitis so histology tells the difference
- can give very erythematous appearance to gingivae which concerns pt
Atrophic lichen planus equivalent on the gingiva
Disease of gum skin covering and not affecting bone or supporting structures so no teeth should be directly lost
Ptx who struggle with plaque control will have more troublesome gingival lichen planus
appearance & management of gingival LP
can be very patchy
some forms more typical reticular pattern seen
OH v important in settling lesion esp interdental, seems plaque driven in most pt
Erythematous band extends the whole way around the upper teeth
No marginal gingivitis
Changes in gingiva are consistent with those higher up in the attached gingiva
Desquamative gingivitis appearance
why can biopsy be difficult for gingival lesions
- risk of damaging attachment area of gingiva/tooth
- adherent attached mucosa damaged lifting from bone
take care deciding to biopsy gingival lesions
difficult to biopsy attached gingiva as can be hard to remove without damaging and to remove from underlying periosteum & must be wary about causing damage to the junctional tissue supporting the tooth
Should only be carried out when there is a good clear margin of gingiva between the tooth and the lesion and ideally taken from high in the sulcus
tongue LP
- dorsum usually idiopathic; loss of papillae & smooth tongue surface
- lateral aspect may have drug / amalgam tigger; amalgam most likely if there is an isolated lateral tongue lesion but look at tongue at rest to see if there is an amalgam contact
- easy biopsy site but painful when healing
contributing factors to LP
most are idiopathic so no known cause
some related to medication esp hypertensives
some related to amalgam
common medications that can cause LP
ACE inhibitors
beta blockers
diuretics
NSAIDs
DMARDs i.e. sulphasalazine
lichenoid drug reaction
more often widespread lesions
often bilateral & mirrored
often poorly responsive to standard steroid tx
managing lichenoid drug reactions
must consider:
- benefit of drug
- risk of stopping drug
(does the benefit of stopping the medical drug outweigh the risk to the pt health; for mild lichen this is unlikely but for significant lichen it is probable where maximum topical/systemic tx likely needed to control symptoms)
- discomfort from symptoms
if in doubt discuss with GP i.e. easy change from ACE inhibitor to AT2 blocker which has same effect on BP not is not seen to be associated with lichenoid reaction
management of amalgam related lichen lesion
if not symptomatic do you consider doing nothing
potentially malignant lesion although LP has very low malignant transformative risk
replacing restoration will increase tooth damage
cost to pt
no routine need for other amalgams to be replaced
consider crown / composite
LP management overall
remove any cause i.e. medicine / amalgam restoration
biopsy unless good reason not to
blood tests - haematinics, FBC
if lupus suspected then antibody screen (ANA, Ro, dsDNA)
for mild intermittent lesions
topical OTC remedies i.e. CHX mw / benzdamine mw
avoid SLS containing toothpaste i.e. sensodyne pronamel & kingfisher
for persisting symptomatic lesions in primary care setting
topical steroids (as for mouth ulcers)
- beclomethasone MDI 0.5mg/puff for 2 puffs 2-3x daily
- betamethasone rinse - 1mg/10ml 2mins x2 daily
for persisting symptomatic lesions in hospital setting
higher strength steroids (puffer/rinse)
skin steroid cream - clobetasol
can be applied in a veneer in gingival lesions
topical tacrolimus - ointment / mw
hydroxychloroquine
systemic immunomodulators - azathioprine, mycophenolate
what must be considered in palatal lesions
lupus must always be considered
Discoid lupus is a solitary lesion found in the oral mucosa where there is association with systemic autoantibodies and systemic lupus erythematosus
histology of lupus erythematosis
atrophic epithelium
basal vascular damage
melanophage
intense lymphocytic infiltrate - is much deeper in the connective tissue and away from the basement membrane - important distinction found in biopsy
GVHD
graft v host disease i.e. after bone marrow transplant / stem cell transplant
why are lichen like lesions important
underlying disease needs consideration as it could be GVHD / lupus
if only oral symptoms treat symptomatically as LP
liaise with physician regarding oral lesions
lupus lesions can be (2)
- only in the mouth (discoid lupus - no antibodies)
- mouth & elsewhere (systemic lupus - ANA/Ro/dsDNA antibodies in the blood
