MUCOCUTANEOUS DISEASES

Question 1

4 Mucocutaneous diseases

Answer 1

• LP
• lichenoid reaction
• DLE
• chronic graft vs bone disease

Question 2

Lichen planus (what is it + location)

Answer 2

• chronic inflammatory condition
• immunologically mediated disease
• premalignant condition
• oral cutaneous genital (oral lesions are typically chronic)
• common 1-4% population

+ 70% of skin lesion pt have oral
10-30% of oral lesion pt have skin

coeliac disease exacerbates it

Question 3

Lichen planus aetiology

Answer 3

• unknow
• immunologically mediated process
• cytotoxic t cells attack basal keratinocytes
• related to: stress, DM, spicy foods, liver disease (hepatitis C)

Question 4

What questions do you ask someone with lichen planus

Answer 4

• ask about drug history
• is it painful?
• what makes it worse (spicy food/brushing teeth)
• onset, where is it most common
• are lips involved?

Question 5

Oral presentation of lichen planus

Answer 5

• asymptomatic or pain with spicy food/brushing teeth
• common in: buccal labial mucosa and tongue
• rare: palate, FoM, lingual aspect
• forms: reticular(typical), erythematous (atrophic), ulcerative(erosive), plaque like, bullous, papular (initial presentation)/ circinate
• symmetrical/mirror image
• Often in areas of friction eg. Koebner phenomenon
• Associated with desquamative gingivitis

Question 6

What is associated to desquamative ginvitis

Answer 6

LP
MMP
PV
DLE

Question 7

Extra oral presentation of LP

Answer 7

-CUTANEOUS= on flexor surfaces (papules red turning violaceous)
+Wickhams striae
-HAIR= scarring alopecia, planopilaris
-NAILS= groovs+pits
-GENITAL= eg. ulcerative+ could be malignant

Question 8

Lichen planus differentials

Answer 8

• lichenoid reaction
• DLE
• Leukoplakia
• candida infection
• epithelial dysplasia
• keratosis
• desquamative gingivitis= PV, MMP, DLE
• chronic graft vs bone disease
• white sponge naevus
• oral hairy leukoplakia

Question 9

Lichen planus management (without drugs)

Answer 9

• Eliminiate provoking factors (eg. rough restoration)
• Reduce chemical irritation (acidic/alcohol)
• Reduce plaque accumulation due to desquamative gingivitis -OHI
• eliminate sodium lauryl sulfates
• smoking cessation+alcohol cessation

Question 10

Lichen planus treatment (with drugs)

Answer 10

THIS IS NOT CURATIVE! it decreases pain and inflammation (controls symptoms)

• betamethasone 500mcg soluble tablet in 20 ml of water QDS for 5 days
• prednisolone
• Tacrolimus (0.03/0.1%) ointment -> calcineurin inhibitor = inhibits IL2 synthesis and t-cell activation = some studies have shown a cancer risk.

azathioprine/dapsone is steroids are not enough

Question 11

Lichenoid reaction subgroups

Answer 11

• oral contact hypersensitivity reaction

- amalgam contact hypersensitivity reaction

Question 12

Aetiology of lichenoid reaction

Answer 12

drug/dental materials causing hypersensitivity

Question 13

Drugs linked to lichenoid reaction

Answer 13

b-blockets -elol 
ace-inhibitors -pril
NSAIDs
allopurinol 
anti-malarials
hypoglycaemic agents

Question 14

Oral presentation of lichenoid reaction

Answer 14

-indistinguishable to LP unless its unilateral/asymmetrical due to oral contact/amalgam hypersensitivity reaction

Question 15

How to resolve lichenoid reaction

Answer 15

• withdraw drug
• remove dental material (always under rubber dam to prevent amalgam tattoo)
• manage lichen planus until this resolved eg. betamethasone

Question 16

Discoid Lupus Erythematosus

Answer 16

• chronic cutaneous and oral disorder
• lichen planus like oral lesions
• scaly patches on sun exposed areas

Question 17

Aetiology of DLE

Answer 17

• autoimmune disorder precipitated by drugs/hormone/environment/viral factors
• autoantibodies and cell mediated immunity against NORMAL cellular components eg. nuclei

Question 18

DLE and lichen planus similarities and differences

Answer 18

similar to OLP and normally occur bilaterally
erythematous areas surrounded by wickhams striae
DIFFERENCES:
DLE is often seen on the palate and is rare in LP

Question 19

Cutaneous DLE

Answer 19

• scaly patched in sun exposed areas
• generalised telangiectasia
• atrophic
• alopecia

Question 20

Management of DLE (management= special investigation AND treatment)

Answer 20

SPECIAL INVESTIGATIONS

• Biopsy
• autoantibodies to normal cellular components like nuclei/cytoplasm

TREATMENT
-ORAL: treat oral lesions like OLP eg. betamethasone/prednisolone/tacrolimus (0.03-0.1%)
-SKIN: Chloroquine and topical corticosteroid (choloquine can cause blue-grey staining)
sun block spf 50
other drugs eg. dapsone

Question 21

Chronic graft vs host disease

Answer 21

• complication following allogenic bone marrow transplant
• 6-24 months post BMT
• skin mouth eyes and liver are involved
• predisposing factors: poorly matched grafts + older
• successful grafts= grafts vs leukaemia effect

Question 22

GVHdisease clinical features

Answer 22

ORAL: 
-reticular erosive ulcerative
-burning mouth symptoms
-xerostomia may follow salivary gland involvement 
-trismus due to sclerotic gvh disease
you see it on the palate like DLE

Question 23

Management of GVH disease

Answer 23

TREATMENT
-analgesic eg. lignocaine/difflam 0.15%
-topical corticosteroid betamethasone
-tracolimus ointment 0.03-0.1%
increase risk of OSCC so monitor