Lichen Planus Flashcards
LICHEN PLANUS
What is lichen planus ?
- Chronic cell-mediated immunological inflammatory condition.
- Caused by immune-mediated cytotoxic T-cells.
- Causing epithelial damage directed against basilar keratinocytes.
- Unknown aetiology.
LICHEN PLANUS
Describe some of the aetiological factors which might possibily be involved in lichen planus ?
- Contact hypersensitivity reaction i.e. amalgam.
- Medication related - beta-blockers, ACE inhibitors, gold, quinine.
- Medical condition related - GvHD, SLE.
- Physical and emotional stress.
- Isomorphic response - i.e. to trauma.
- Isotrophic response - i.e. to local skin disease (VZV).
- Systemic infection i.e. Hep C causing modification of self-antigens on basal keratinocytes.
LICHEN PLANUS PRESENTATION
Describe the histological presentation of lichen planus.
- Parakeratosis.
- Orthokeratosis of epidermis.
- Chronic T-cell inflammatory infiltrate in basement membrane from CT.
- Patchy acanthosis.
- Saw tooth rete pegs.
- Civatte bodies.
- Basal cell damage.
LICHEN PLANUS PRESENTATION
Describe the signs/symptoms of lichen planus.
- Pain (exacerbated by SLS, citrus, spicy).
- Burning mouth sensation.
- White/red patches in the mouth.
- Desquamative gingivitis.
LICHEN PLANUS PRESENTATION
Describe desquamtive gingivitis.
- Full thickness erythema of the attached and unattached mucosa.
- Not caused by presence of plaque, but can be exacerbated by it.
LICHEN PLANUS PRESENTATION
Name some subtypes of lichen planus.
- Minor and major erosive/atrophic.
- Reticular.
- Ulcerative.
- Plaque-like.
LICHEN PLANUS PRESENTATION
What mucosal surfaces of the mouth does lichen planus most commonly affect ?
- Buccal mucosa.
- Lateral border of the tongue.
- Gingiva.
LICHEN PLANUS INVESTIGATIONS
What initial investigtaions would you wish to carry out where you suspect your patient has lichen planus ?
Incisional biopsy.
Blood tests - haematinics, FBC, autoantibody screen.
LICHEN PLANUS MANAGEMENT
Where you suspect your patient has drug-related lichenoid reaction - how would you manage this ?
Discuss with GP - risk:benefit analysis of stopping/changing their medication.
LICHEN PLANUS MANAGEMENT
Where you suspect your patient has contact sensitivity lichen planus to an amalgam restoration - how would you manage this ?
Replace restoration with composite.
LICHEN PLANUS MANAGEMENT
Your patient has mild/intermittent lichen planus - how would you manage this patient is primary care ?
Chlorhexidine MW 0.2% - 10ml 2x daily for 2 mins.
Benzdiamine MW 0.15% - 15ml 2x daily for 2 mins.
Reassurance.
Suggest patient avoids trigger foods.
LICHEN PLANUS MANAGEMENT
You prescribe your patient chlorhexidine gluconate MW 0.2% - what is the properties and mechanism of action of this MW ?
- Analgesic, anti-inflammatory, bacteriostatic, bacteriocidal.
- Widespread antimicrobial.
- Binds to negatively charged phosphate ions on bacteria surface membrane.
- Alters the integrity of the cell membrane and causes apoptosis.
- Binds to hard and soft tissues in the mouth for slow release.
LICHEN PLANUS MANAGEMENT
You prescribe your patient benzdamine MW 0.15% - what is the properties and mechanism of action of this MW ?
- NSAID.
- Inhibits the synthesis of IL1 and TNF-a.
- Which prevents synthesis and chemotaxis of further pro-inflammatory markers (IL6 and IL8).
- Results in anti-inflammatory and analgesic effect.
LICHEN PLANUS MANAGEMENT
Your patient presents with major/persistent lichen planus - how do you manage this patient in primary care setting ?
- CHx gluconate MW 0.2% 20ml for 2 mins 2x daily.
- Benzdamine MW 0.15% 15ml for 2mins 2x daily.
- Avoid trigger foods and SLS-free toothpaste.
Prescribe either -
* Beclomethasome MDI 0.5mg 2x puffs 2-3x daily.
* Betamethasone MW 1mg tablet in 10-20ml of water for 2mins daily.
LICHEN PLANUS MANAGEMENT
Your patient with persistent/major lichen planus presents at their 2 week review following your primary care management and their condition has NOT improved - how do you then manage this patient ?
Referral to secondary care - OM.
LICHEN PLANUS MANAGEMENT
You work in secondary care setting - referral from a GDP is made and the patient presents with persistent/major lichen planus which has been unresponsive to primary care treatment - what are your options for managing this patient ?
- Short-term systemic steroids - prednisolone.
- Topical higher strength steroids - tacrolimus or clobetasol (gingival veneer).
- Immune-modulator medication - hydroxychloroquine, mycophenolate or azathioprine.
LICHEN PLANUS MANAGEMENT
Describe the mechanism of action of mycophenolate.
- Depletes guanosine nucleotides in T and B cells.
- Therefore, inhibits T and B cell proliferation.
- Which suppresses cell-mediated immune response.
LICHEN PLANUS MANAGEMENT
Describe the mechanism of action of azathioprine.
- DMARD medication.
- Purine metabolism antagonist.
- Inhibits DNA, RNA and protein synthesis of pro-inflammatory cells.
LICHEN PLANUS MANAGEMENT
Describe the mechanism of action of beclomethasone & betamethasone.
- Adrenocorticosteroid.
- Decreases capillary permeability.
- Decreases leukocyte and fibroblast migration.
- Controls rate of protein synthesis.
- Therefore, has anti-inflammatory effect.
