lichen Planus and oral vesicullobullous disease Flashcards
what areas of the body can lichen planus effect?
- Skin
- Scalp
- Genital
- Oesophageal
what is oral lichen planus (OLP)?
OLP is a cell mediated autoimmune condition which targets (oral) keratinocytes.
what causes OLP?
Mostly idiopathic however aetiological factors may be:
drugs (drug induced OLL)
mercury( amalgam associated OLL).
what is this?
signs of oral lichen planus
what are the intraoral features of OLP?
o Keratosis: reticular (web like) / annular(ring like) / plaque like keratosis may be present.
o Desquamative Gingivitis o Areas of atrophic
inflamed oral mucosa
o Mucosal erosion or even frank ulceration
o Bullous lesions.
what type of OLP is this?
Reticular
what does this show?
Lichenoid drug reaction
what are the potential complications of OLP?
Pain –quality of life, nutrition and oral hygiene measures
Periodontal attachment loss: this is an indirect effect when oral hygiene measures are compromised secondary to discomfort.
Malignancy risk: OLP is a potentially malignant lesion (transformation risk incidence of 1%)
what are the differential diagnosis of OLP?
GVHD, HCV, Lupus
what is GVHD?
Graft vs host disease. Where the graft which has been transplanted starts attacking the bodies own self tissues.
what is this
Presentation of GVHD but may present similarly to OLP
What is HCV?
Hep C. It may present similarly to OLP
what does this show?
Both Lupus and OLP present identically even histopathologically they both have lichenoid appearances
Incisional or punch biopsys are often taken of OLP. what would they show histopathologically?
evidence of basal membrane immune mediated damage
sub basal lymphocytic band
hyper/ hypokeratosis, although this may not be evident in ulcerated areas
what other investigations can be done to diagnose OLP?
- DirectIF
- Epidermal patch testing
- HCV serology
- Autoimmune profile
How do you manage OLP?
identify and eliminate the cause.
Remove amalgam if they are believed to be the cause
Drug lichnoid reactions- liase
What topical steroids could be use?
Betnasol mouthwash
Barrier agents such as orobase which is a carboxymethylcellulose or hyaluronic based preparations such as Gelclair or Gengigel.
Chlorhexidene
When should you refer?
In medium to severe cases which are unresponsive to first line therapy should be referred to an oral medicine specialist.
High Potency Topical Steroids such as Clobetasol Proprionate 0.05% ointment mixed on a 1:1 basis with Orabase
Topical Tacrolimus 0.01% ointment mixed on a 1:1 basis with Orabase
what systemic therapy can be used for OLP?
Reducing course of Prednisolone eg.40 -30- 20-10 mgs reducing over a period of 1 month.
Long term Systemic Therapy for specialist use in recalcitrant OLP
Should you review OLP?
Yes! Potentially malignant.
Need to involve other care teams if extra oral
What are the two types of pemphigoid?
Bullous pemphigoid- usually just skin
Mucous membrane pemphigoid- Effects mucosa and +- skin
what causes mmp?
t is an autoimmune disease with antibodies directed at antigen/s in epithelial basement membrane resulting in a split and blister formation at this level.
Specifically BP 180 at the basement membrane
How does MMP present?
Desquamative gingivitis
Can be oral, pharyngeal and genital.
what is this?
The presentation of MMP
what are the intra oral findings with MMP?
Mucosal inflammation
Mucosal erosion and frank ulceration
Blister formation
Desquamative gingivitis
Scarring
what does this histopathology slide show?
Pemphigoid ( blister at the basement membrane_
what technique is this and what does it show?
Direct immunofluoresence
how does indirect immunofluoresence differ from direct?
indirect uses a blood sample.
what are the complications of mmp?
Skin involvement: blistering, ulceration
Genital involvement: blistering, ulceration and scarring leading deformities
Pharayngeal involvement: blistering, ulceration and scarring →stricture formation and dysphagia
Oral involvement: blistering, ulceration and periodontal tissue loss ( secondary to inability to maintain adequate oral hygiene)
what are the complications of MMP in the eye?
Tethering of conjunctiva to sclera (symblepharon)
Inversion of eyelashes (entropion)
Scleral irritation and inflammation (blepharitis).
what are the topical treatments for mmp?
topical steroid- dermovate
topical immunosuppressants
what systemic treatment is given?
Steroids- prednisolone
sliding dose- ( decreases as time goes on)
Give an example of a systemic immunosuppressant?
Mycophenolate Mofetil
Inhibits the synthesis of the purine nucleotide guanine
Inhibits the proliferation of B and T cells in response to antigen stimulation
what is pemphigus vulgaris?
Autoimmune Disease
Antibody mediated
Target: desmosomal proteins(DSG1,3)
PV often starts with oral lesions with later skin involvement
Complications of disease and therapy
what causes PV?
Antibodies are directed against:
– Desmoglein (DSG) 1(mainly expressed in oral mucosal desmosomes
– DSG 3 which is mainly expressed in skin desmosomes.
what are the intraoral findings of PV?
– Mucosal erosion and frank ulceration even including hard and soft palate
– Blisters: typically burst
– Desquamative gingivitis
what are the Extra oral findings of PV?
Skin lesions: Itchy erythematous
papules and blisters
» Genital lesions and soreness, scarring
» Pharyngeal lesions, possibly with scarring and dysphagia
what does this slide show?
Pemphigus
what does this direct immunoflouresence show?
pemphigus
How do you treat and manage Pv?
Acute control: systemic & topical steroids
Maintenance-topical & systemic steroids & MMF/ Azathiaprine
mulitdisiplinary care!!
what drugs can induce pemphigus oral ulceration?
induced by drugs with a sulphydryl group such as captopril
what is paraneoplastic pemphigus?
the pemphigus related oral ulceration but with associated malignancy!
what are the complications of PV?
Skin involvement: blistering, ulceration, fluid loss- shock – death.
Genital involvement: blistering, ulceration
Pharayngeal involvement: blistering, ulceration and
scarring.
Oral involvement: blistering, ulceration . Loss of periodontal tissues (secondary to inability to maintain adequate oral hygiene)
what are the other vesiculobullousdisorders which have oral manifestations?
- Dermatitis Herpetiformis
- EpidermolysisBullosa Acquisita
- ErythemaMultiforme
- Viral infections can cause blisters !!
