Lichen Planus Flashcards by Y Clayton

What is lichen planus?

Chronic, inflammatory mucocutaneous disease of unknown aetiology

How well did you know this?

Not at all

Perfectly

What is the likely aetiology of lichen planus?

Cell mediated immunological reaction within affected tissues due to an unknown trigger

How well did you know this?

Not at all

Perfectly

Epidemiology of lichen planus

Common (0.5-2% of adult population)
Female predilection 2:1
Age of onset around 30-60

How well did you know this?

Not at all

Perfectly

Why is lichen planus likely to be a cell mediated immunological reaction?

There is an accumulation of T cells within the epithelium along with macrophages, langerhans cells and local production of cytokines

How well did you know this?

Not at all

Perfectly

Why is lichen planus likely to be an autoimmune disease?

Females > males and it is associated with other AI diseases e.g. primary billary cirrhosis

How well did you know this?

Not at all

Perfectly

What type of lichen planus has a known HLA association?

VVG variant (vulvovaginal-gingival)

How well did you know this?

Not at all

Perfectly

What are the cutaneous features of lichen planus?

4 Ps - polygonal, purititc, purple papules commonly found on the flexors of the wrists, lumbar region, anterior leg (shins) and genitalia

How well did you know this?

Not at all

Perfectly

What are the features of the vulvovaginal gingival variant of lichen planus?

Lesions affecting the vulva, vagina and gingiva

Scarring type is associated with lacrimal duct scarring, perforated eat drugs, hoarse voice and difficulty swallowing

How well did you know this?

Not at all

Perfectly

How long do cutaneous LP lesions last?

Around 2 years (shorter duration than oral LP)

How well did you know this?

Not at all

Perfectly

What are the phenotypes of oral lichen planus?

Reticular
Papular
Erosive
Atrophic
Plaque type
Bullous

How well did you know this?

Not at all

Perfectly

List the oral features of lichen planus

Bilateral, symmetrical lesions commonly on the buccal mucosa, labial mucosa, dorsal tongue, gingiva 
Striations 
Papules 
Atrophic areas 
Erosions 
Plaques

How well did you know this?

Not at all

Perfectly

What are striations?

Sharply defined and white
May appear lacy, starry or annular
Can be firmer than the surrounding mucosa

How well did you know this?

Not at all

Perfectly

What are papules?

Pinpoint, flat topped papules (can be white, red or purple) which may be interspersed with the striate

How well did you know this?

Not at all

Perfectly

Describe atrophic lichen planus lesions

Red areas of mucosal thinning, may be associated with striate

How well did you know this?

Not at all

Perfectly

Describe erosion lichen planus lesions

Shallow and irregular areas of epithelial destruction which may be covered in a slightly raised, yellow fibrin layer
Margins may be depressed due to fibrosis and healing at the periphery

How well did you know this?

Not at all

Perfectly

Describe plaque-like lichen planus lesions

Dense thickening of the mucosal tissue (tends to be white)

How well did you know this?

Not at all

Perfectly

What % of oral LP have it confined to the gingiva only?

10%

How well did you know this?

Not at all

Perfectly

What is oral postinflammatory hyperpigmentation?

Brown or black pigmentation of the mucosa following the lichenoid lesion distribution as a result of an inflammatory response

Describe the disease course of lichen planus

Periods of relapse and remission

What type of lichen planus is more persistent?

Plaque like lesions

Common CO for lichen planus

Slight stiffness of mucosa
Soreness or oral discomfort (esp with atrophic or erosive types) - difficult to eat
May be asymptomatic due to insidious onset

Describe oral lichen planus that is confined to the gingiva only

Lesions tend to be atrophic and the gingiva is shiny, inflamed and smooth (desquamative)
Straie are uncommon
Plaque accumulation present due to difficulty cleaning

Histological signs of lichen planus

Compact, dense band of lymphocytic infiltrate under the epithelio-mesenchymal junction, or partially disrupting the epithelium
Saw tooth profile and rete ridges
Hyperkeratosis and acanthosis
Apoptotic body (liquefaction degradation)
Widening of basement membrane
Melanin drop outs

Special IX for lichen planus

Biopsy for histopatholology

- Immunoflouresence to rule out mmp, pv and dle

Management pathway for lichen planus

- Diagnosis - Supportive - not infectious - Topical agents +/- systemic depending on severity - Maintainence - Monitoring

What topical agents are used for lichen planus

Difflam or lidocaine

What topical therapies are used for lichen planus

Corticosteroids**, fluticasone, mometasone or calcineurin inhibitors

What systemic therapies are used for lichen planus

Corticosteroids***, hydroquinone, azathioprine or methotrexate

Treatment of gingval lichen planus

- Difficult - Triamcinolone paste (corticosteroid) - Tacrolimus mouthwash if unresponsive

Differential diagnosis of oral lichen planus

- Lichenoid reaction - Frictional keratosis - Leukoplakia - If erythematous LP then erythematous candidiasis - Lupus - Pemphius and MMP

Referral for oral lichen planus

- Unsure of diagnosis - Speckled lesion - suspicious - Unresponsive to steroids

What is the oral disease severity score?

Categories OLP as mild, moderate and severe based on site score, activity score and pain score

What type of OLP tends to have the highest severity score?

Ulcerative oral lichen planus

What are oral lichenoid lesions?

Lichen-planus like lesions that are caused wither by systemic drug treatment, or those where the histological picture is not diagnostic for LP

Describe the clinical appearance of oral lichenoid lesions due to amalgam

- Small, unilateral lesions localised around amalgam restorations

Describe the clinical appearance of oral lichenoid lesions due to drug therapy

- Widespread lesions in the mouth and skin associated with the onset of a drug - Asymmetrical

What drugs are associated with oral lichenoid lesions

- Colloidal golds - Antihypertensives - Oral hypoglyceamics - NSAIDs - naproxen - Penecillamine - Tricyclic antidepressants - Antimalarials - Biologics

What dental materials are associated with oral lichenoid lesions

Amalgam, composite, acrylic, cobalt and nickel

Describe the pathology of OLL due to dental materials

Contact hypersensitivity (delayed = type IV) due to alteration in antigenicity of basal keratinocytes by the release of dental materials

When is the diagnosis 'oral lichenoid lesion' made?

- Histopathology not diagnostic of lichen planus - Histopathology is diagnostic of OLP but clinically doesn't match - Clinical and histology indicates OLL

What is the malignant potential of oral lichen planus

Reports suggest 1-4% change over 10 years (however this is controversial and may be considered as <1%)

List risk factors for increased risk of malignant change in OLP lesions

- Smokers - Females - Lesions on the tongue - Atypical lesions - Red lesions

What is desquamative gingivitis?

A clinical description of erythematous gingiva, desquamation and erosion of the gingival epithelium and blister formation - usually affecting whole width of the attached gingiva around teeth

What is desquamative gingivitis associated with?

- Lichen planus (most common) - MMP - Pemphigus vulgaris