Mucocutaneous Diseases Flashcards
Demographic of lichen planus?
0.5-2% of the population
4th-8th decade
60% women
Can affect children (2-3%)
Europeans/Indians > Chinese/Malay
How long are LP skin lesions active for?
Around 18 months on average
Aetiology of lichen planus?
Unknown, may be autoimmune or related to stress, spicy foods, diabetes or liver disease
Symptoms of OLP?
Asymptomatic
Pain & discomfort especially when eating spicy/ acidic/ citrus foods or brushing teeth
Time present varies
Pts may have concerns about appearance especially if lips & gingiva involved
Lesions often in areas of increased friction (koebner phenomenon)
7 types of presentation of OLP?
- Reticular
- Atrophic (erythematous)
- Erosive (ulcerative)
- Papular
- Bullous
- Plaque like
- Circinate
Extra-oral symptoms of LP?
Cutaneous (15%)
- Purple polygonal pruritic papules
- Symmetrical distribution, on flexor surfaces of wrists/shins or sites of trauma (Koebner phenomenon)
- Surface network of fine white striations “Wickham’s striae”
Dystrophic nails (10%)
- Longitudinal grooving & pitting & can get complete nail loss
Vulvovaginal-gingival syndrome
- Ulcerative, symptomatic LP on gingiva, vulva & vagina
- Progressive vulval disease leading to scarring
Hair
- Lichen planopilaris (affecting scalp) => scarring alopecia
Differential diagnoses of oral lichenoid lesions?
Lichenoid reactions
Dysplasia
Leukoplakia
Keratosis
DLE
GVHD
Gingival form - i.e. desquamative gingivitis - PV, MMP
What should patient’s be informed of when diagnosed with OLP?
That there is risk of malignant transformation (~0.5-2%)
Pts should ‘monitor’ disease & attend dentist regularly
How to manage symptomatic LP?
Eliminate provoking factors (e.g. mechanical trauma from sharp cusp/ill-fitting denture)
Reduce chemical irritation (spicy/acidic food & SLS-free toothpaste in desquamative gingivitis)
Good OH & alcohol-free/CHX mouthwash
How to manage asymptomatic LP?
Reassure pt & review
Pt should be informed of malignant risk & encouraged to attend regularly
Pt should be made aware lesions may develop outside the mouth
Advise to:
- Maintain good OH
- Smoking cessation
1st line drugs for LP?
Topical corticosteroids
- Hyrocortisone, betamethasone or benzydamine (Difflam)
Systemic
- Prednisolone or deflazacort
2nd line drugs for LP?
Topical calcineurin inhibitors (immunosuppressants)
- Calcineurin
- Ciclosporin
- Tacrolimus
- Pimecrolimus
What drugs would be given for severe LP?
Systemic corticosteroids
Ciclosporin
Azathioprine
Mycophenolate mofetil
Dapsone
Thalidomide
What is lichenoid reaction?
Similar in clinical presentation & histology to LP but more defined aetiology
Aetiology of lichenoid reaction?
Drug induced
or
Dental material related
Clinical presentation of lichenoid reaction?
Similar to LP but likely to be erosive form (soreness) & affect palate/tongue
Unilateral/bilateral, may be asymmetric if reacting to specific materials
May be ulcerative
Aetiology of lichenoid reaction?
Drug-induced:
- Beta-blockers
- ACE inhibitors
- Diuretics
- NSAIDs
- Gold salts
- Methyldopa
- Oral hypoglycaemics
- Pencillamine
- Anti-malarial
- Allopurinol
Dental material induced
- Metallic restorative materials (e.g. gold/ amalgam/ nickel)
- Resins (BisGMA)
Histopathology of lichen planus?
+/- Hyperkeratosis
Saw-tooth rete ridges in epidermis
Basal cell liquefaction/ degeneration
Lymphocyte-dominant subepithelial band
Histology of lichenoid reaction?
Same as LP
Deeper & less well-defined infiltrate
Large number of plasma cells & eosinophils
Management of lichenoid reaction?
Good drug history - if possible, withdraw drug & monitor
Local cause - patch test
Manage as LP until resolves
What is discoid lupus erythematosus?
Chronic indolent cutaneous & oral disorder => scaly skin patches in sun-exposed areas & LP-like oral lesions
Aetiology of DLE?
AI disorder - autoantibodies & cell-mediates immunity against normal cellular components
May be precipitated by drugs, environmental, hormonal or viral factors
Oral presentation of DLE?
Similar to oral LP - bilateral on labial, buccal or alveolar mucosa or vermillion border but also palate lesions present (rare in LP)
Less well-demarcated erythematous areas surrounded by border of fine white striae
May ulcerate - esp. in active lesions or cases progressing to SLE
Cutaneous presentation of DLE?
Scaly atrophic plaques on sun-exposed skin (sun protection is vital)
One or more oval plaques (red & scaly with keratin plugs) - may involve oral & genital mucosa, skin & hair
Well-demarcated, red, atrophic, scaly & show keratin plugs in dilated follicles generalised telangiestasia
Scarring => Alopecia & pigementation on scalp
Management of DLE?
Oral lesions as with LP
Cutaneous lesions = suncream (SPF 50) & chloroquine & potent steroids
