Oral Lichen Planus Flashcards
Diff Dx when you see white striae
Differential Diagnosis:
• Oral Lichen Planus
• Oral Lichenoid Reactions
– Oral Lichenoid Contact Lesions
– Oral Lichenoid Drug Reactions
– Oral Lichenoid Lesions of Graft vs Host Disease
• Systemic or Discoid Lupus Erythematosis
• Hepatitis C InfectionsEpidemiology of OLP
- Prevalence 1-2%
- Occurs in middle-age
- Slight predominance in females
- No racial predilection
- Approximately 60% are symptomatic.
- When symptomatic, it is a sensitivity to spicy foods or acidic foods, pain (i.e. annoyance) felt when brushing, not necessarily needing pain killers but bothersome
• Most patients have intermittent symptoms over time (exacerbation/remission)
Oral Lichen Planus: Features
• Characteristic lacy
appearance, with radiating lines, most often in a reticular
appearance (Wickham’s striae),
• can be punctate
• can be plaque-like lesions (mistaken as a leukoplakia but histopathology will show OLP)
• White changes with associated erythema, ulceration, or
occasionally bullae will result in symptoms of burning &
sensitivity to acidic/spicy foods.
• BILATERAL
• BUCCAL MUCOSA MOST COMMON (but can be anywhere)
• 25% show extra-oral lesions
• No causative factor evident in history
With OLP, changes in pigmentation are caused by…?
Some pigmented changes (post inflammatory pigmentation) caused by Melanocytes secreting more melanin in response to inflammation
Erosive OLP
Erosive form of lichen planus (gingival lichen planus) described as:
- Lacy
- Radiating
- Reticular
- Wickham’s striae
- Bilateral
- Erosive
- Ulcerative
Ulcerative OLP
Inflammation so significant that epithelium deteriorates
And ulcerates; LOTS OF PAIN; difficulty eating or drinking
Described as:
- Lacy
- Radiating
- Reticular
- Wickham’s striae
- Bilateral
- Erosive
- Ulcerative
Extra-oral lesions of OLP
Itchy papules particularly on the back of the hands associated with lichen planus
Vulval lichen planus
Diagnosis of Oral Lichen Planus
- Incisional biopsy is mandated to confirm diagnosis of OLP, to differentiate between OLP and lichenoid reactions, and to rule out dysplasia or carcinoma
- Biopsy white changes on non-keratinized mucosae, not red nor ulcerated areas
Histopathology of OLP
• Dense subepithelial lymphocytic infiltrate
• Band like layer of inflammatory lymphocytes
• Severe basal cell destruction
• Increase in the number of intraepithelial lymphocytes
• Degenerating basal keratinocytes form colloid or
Civatte bodies, which appear as homogenous
eosinophilic globules
• Hemidesmosomes are disrupted, resulting in microscopic clefts between the epithelium and the connective tissue
One histology difference between OLP and Lichenoid Mucositis
In lichenoid mucositis there may be a mixed infiltrate
with perivascular infiltration
Pathogenesis of OLP
OLP is a CD-8 T-cell mediated response
1) Antigen-specific CD8+ T cells are activated in the OLP epithelium.
2) Activated Antigen-specific CD8+ T cells (CTL) trigger keratinocyte apoptosis, possibly via TNF-a secretion
3) activated CTL undergo intralesional clonal expansion and release soluble mediators (cytokines/chemokines) which stimulate lymphocyte extravasation from the local microvasculature and migration towards the epithelium
4) Recruited lymphocytes secrete MMP-9, which causes epithelial basement membrane disruption
5) Epithelial basement membrane disruption (i) facilitates the passage of lymphocytes into the epithelium and (ii) denies keratinocytes a cell survival signal, resulting in further keratinocyte apoptosis.
Malignant Transformation in OLP Patients
Higher risk than general population but still low
In a systemic review with 16 studies, 1% of OLP patients/year with an average age 61, females>malesClose surveillance needed
Oral Lichenoid Reactions
• Oral lichenoid contact lesions
– Amalgam or other metal contact sensitivity
– Foods/ flavoring
• Oral lichenoid drug reactions
Large Medication group Contributing to Lichenoid Rxns
ANTIHYPERTENSIVES
- Atenolol
- Enalapril
- Hydrochlorothiazide
- Methyldopa
- Metoprolol
- Thiazide Diuretics
Lichenoid Reactions: Features
White changes indistinguishable to OLP by
appearance alone
• If lichenoid reaction has a systemic cause, lesions
may be widespread (including extra-orally)
• Skin lesions are more common in lichenoid reaction
to drugs.
• If lichenoid reaction has a local cause the lesion will
generally be found at the site(s) of contact.
• Causative factor is evident in history: medication
use, dental restorations, oral habits, and food intake
is important.
• Lichenoid reactions may develop after exposure to a
medication for periods of >1 year
Diagnosis of Oral Lichenoid Reactions
• Incisional biopsy is mandated to
differentiate between OLP. Perivascular
mixed inflammatory infiltrate often seen.
• Histopathologist may use the term
“lichenoid mucositis”
• Biopsy white changes on non-keratinized
mucosae, not red nor ulcerated areas
• Patch testing to mercury or amalgam (or
other metals) is usually positive in patients
with lesions in close proximity to an
amalgam or metal-containing restoration.
Treatments for OLP (RCTs)
- Corticosteroids
- Calcineurin inhibitors
- Retinoids
- PUVA
- Oral Hygiene
- Other treatments
….there is insufficient evidence to support the superior effectiveness
of any specific treatment
What we do for OLP patients?
Dexamethasone Elixir or Solution 0.5mg/5ml
• Indicated for multiple or difficult to reach
lesions
– Disp: variable volumes
– Label: swish and spit with 5-10 ml for 5
minutes up to 4 times a day and expectorate
• Fluocinonide 0.05% gel or ointment (creams
are contraindicated)
• Indicated for easily accessible lesions/only a few lesions
– Disp: variable volumes (15-30g tubes)
– Label: rub in a thin film over areas 3x/day
(after meals and at bedtime)
– Do not use for more than 2 weeks
More severe cases/ pt not responding:
Ultra-Potent Corticosteroids
• Clobetasol or halobetasol gel or ointment 0.05%
– Disp: 15g tube
– Label: apply a thin film over area twice a day
– Do not use for more than 2 weeks
• Clobetasol may also be compounded into 0.05%
solution (not covered by insurance)
Topical tacrolimus
• Calcineurin inhibitor • Prevents T-cell activation • Same family as cyclosporine A • Comes as an ointment (0.03 or 0.1%) • Tacrolimus may also be compounded into a 0.5mg/5ml solution (not covered by insurance)
Systemic Agents
- OTC (curcumin 1500mg twice a day)
- Prednisone
- Mycophenolate Mofetil
- Azathioprine
- Others
