Lichen Planus Flashcards
What is lichen planus?
A chronic disease, affecting 1% of the population.
Typically those aged 30-50
Can be idiopathic, drug related, or rarely related to systemic disease.
What types of lichen planus are there?
Reticular
Atrophic/erosive
How would you determine if a lichen planus was atrophic?
If there is an accompanied erythemous change (redness)
How would you determine if a lichen planus was erosive?
If there is yellowish fiberous covering over the base of the connective tissue, where there is very little epithelium left.
Histologically how would you identify lichen planus?
Chronic inflammatory cell infiltration
Saw tooth rete ridges
Basal cell damage
Partchy acanthosis
Parakeratosis
What is the mechanism by which the epithelium changes during a lichenoid reaction?
- Lymphocyte activation
- Overeaction to normal triggers
- Can be triggered by hep C, herpes, amalgam, medicines.
Which drugs can trigger a lichenoid reaction?
ACE inhibitors
Beta-adrenergic blockers
Diuretics – Bendroflumethiazide, frusemide
NSAIDs
DMARDs
Gold
What can trigger lichenoid reactions?
Genetic factors
Physcial/emotional stress
Injury to skin
Localised skin disease
Systemic viral infection
Contact allergy (metals/amalgam)
Medications
What are the symptoms of lichen planus?
Often none
Thinning of epithelium may lead to sensitivty to hot/spicy food
Burning sensation in the mucosa
List two other conditions which gingival lichen planus may be confused with?
Gingival pemhigoid and plasma cell gingivitis.
Why might it be challenging to biopsy suspected gingival lesions?
Could damage junctional tissues attached to the bone/tooth. Risk loss of attachment for a biopsy that MAY be nothing.
How would you differentiate between plaque induced gingivitis and gingival lichen planus?
No clear band around the tooth
No enlarged tissue onto the tooth
Colour is consistant with that of tissue further down the tooth
What should be considered when taking a biopsy of the tongue?
Easy to take the sample but may be painful when healing.
What is the cause of lichen planus on the tongue?
Its usually idopathic, but lateral lesions may be caused by nearby amalgam.
Which metal in an amalgam filling is the cause of lichenoid reactions?
There has not been any one agent identified.
When should you consider removal of an amalgam to manage a lichenoid reaction?
If it is potentially malignant
If it symptomatic
What are the main management principles for lichen planus?
Removal of causative agent
Biopsy
Blood tests
Local topical agents
Topical steroids
What topical steroids should be given in a primary care setting?
Beclomethasone MDI 0.5mg/puff, 2 puffs 2-3/day
Betamethasone rinse, 1mg/10ml, 2mins/twice daily
When should topical steroids be prescribed for oral lesions?
If they are persisting beyond typical remedies.
If they are symptomatic.
What treatments for lichen planus can be given in a hospital setting?
Higher stregnth steroids (clobetasol)
Topical tacrolimus
Hydroxychloroquine
Systemic immunomodulators
What is graft versus host disease?
A disease where the host immune cells reject grafted tissue, resulting in systemic issues including possible lichenoid reactions.
In lichen planus Skin cases what is the percentage you are also likely to have oral lesions?
- 50%
In Lichen Planus oral cases what is the percentage with skin lesions?
- 10-30%
What type of Lichen Planus is this?
- Reticular
What type of Lichen Planus is this?
Atrophic / erosive
What type of Lichen planus is this?
- Ulcerative
What are the Oral lichen planus sites?
- Buccal mucosa
- Gingivae (Desquamative Gingivitis)
- Tongue (lateral aspect, dorsum)
- Lips
- Palate
What is the most common oral site for Lichen planus?
- Anywhere on Buccal mucosa but more likely on
- Anterior at commisure
- Mid
- Posterior around 3 rd molar tooth
- An easy biopsy site
When found in Isolation what is Gingival Lichen planus also called?
- Desquamative gingivitis
- Has very erythematous appearance
What is very important in settling gingival lichen planus?
- OHI
- Esp interdental
- Seems plaque driven in many pts
What lichen planus is this?
- Gingival lichen planus
When Lichen planus is found on the Dorsum of the tongue what is its trigger?
- Usually idiopathic
- Loss of papillae and smooth tongue surface
When Lichen planus is found on the lateral aspect of tongue what is the trigger usually?
- Drug or amalgam trigger
- Amalgam most likely if there is isolated lateral tongue lesion
- Drug if multiple lesion
What is this an example of?
- Tongue lichen planus
What is this a type of ?
- Lip lichen planus
During a lichenoid reaction what occurs histologically?
- Chronic inflammatory cell infiltrate
- Saw tooth rete ridges
- Basal cell damage
- Parakeratosis
Describe what is going on histologically in this picture
What other sites of the body can be affected by Lichen Planus?
- Skin
- Scalp
- Genital
- Hair
- Nails
Histologically what disease is this picture showing?
- Lichen planus
- Clear T cell infiltrate into the basal membrane area of connective tissues
- The dark purple lymphocytic band hugging the basement membrane is key diagnostic feature of LP
Describe this Lichenoid reaction
- Chronic inflmmatory cell infiltrate (T cell)
-Saw tooth rete ridges - Basal cell damage
- Patchy acanthosis of epithelial layer
- Parakeratosis of superficial epithelium
Using what occurs histologically what info does this give us in regard to Lichen Planus as a disease?
- Shows lymphocyte activation which means the body is attempting to remove a perceived threat
- Most likley the langerhans cells in epithelium are presenting an antigen which triggers an immune response (T lymphocytes) to remove chronic irritation - causing change in epithelium
- Lichen Planus does not have singular cause
What are some other thoughts to cause of LP?
- Genetic predisposition
- Physical and emotional stress
- Injury to skin called koebnerisation
