Vesiculobullous and Ulcerative Lesions part 1 Flashcards
oral lichen planus seen _____ frequently than cutaneous lichen planus
more
which type of lichen planus is more persistent and more resistant to tx
oral lichen planus
what ages get lichen planus
- occurs in 4th-8th decades
- mean age in 5th decades
- rare in children
what is the incidence of lichen planus
-3-4% incidence; 25% with oral lesions have concomitant skin lesion
- 0.5-1% cutaneous incidence; 50% also have oral lesions
- white females (60%)
what are the frequency of sites of lichen planus
- bilateral and often quasi-symmetric distribution
what is the oral site frequency of lichen planus
- buccal mucosa
- tongue
- gingiva
- lips
what are the skin sites in LP
- forearm
- shin
- scalp
- genitalia
what is the pathophysiology of LP
- autoimmune disease; t-lymphocytes attack langerhan cells in epithelium of affected areas
- causes chronic inflammatory lesions with varying episodes of intensity
- not infectious
- not hypersensitivity
what is the etiology of LP
- NSAIDs - ibuprofen and naproxen
- various medications for heart disease and HTN, and RA - hydrochlorothiazide
- hep C and other types of liver disease
- vaccines - Hep B, various flu vaccines, COVID vaccine uncertain
- food allergens
what are instigating factors for LP
- co-morbidities such as DM
- alcohol, tobacco
what is the clinical presentation of LP
erythematous
- ulcerated
- keratotic triations
- episodic pain to severe discomfort
what are the clinical symptoms for LP
- asymptomatic
- itching
- episodic pain
- severe discomfort
what are the clinical types of LP
- reticular
- erosive
- patch
- bullous
what is the most common LP
reticular
what is the most painful LP
erosive
what LP stimulates dysplasia
patch
what LP is clinically similar to diseases of greater morbidity
bullous
how is reticular LP described clinically
lacy
- striated
- wickham striae
where is erosive LP seen
- buccal and labial mucosa
- tongue laterodorsum
- gingiva
- palate
describe the clinical presentation of erosive LP
- large, irregular atrophic erythematous patches diffuse outlines
- progress to ulcerations, pseudomembranous cover
what are the symptoms of erosive LP
- epsidoic pain to severe discomfort
- symptoms may persist weeks or longer
- symptoms result in weight loss, nutritional deficiencies and depression
what is the DDX for LP
- lichenoid dysplasia
- contact stomatitis
- lichenoid reaction
what are the treatment goals for lichen planus
- there is no cure
- reduce length and severity of symptoms
- resolve oral mucosal lesions
- reduce risk of malignant degeneration to squamous cell carcinoma
what are the tx issues with LP
- maintain good OH because good OH reduces symptom severity
- OH is difficult to accomplish during active disease
what are the medications used to treat LP
- oral anesthetic rinse - 1% dyclonine solution
- antibiotics
- antifungals with steroid- nystatin with triamcinolone
- corticosteroids
what is the treatment regimen with topicals for LP and why is it used
- 4-6 week course
- most popular, best success with steroid carriers
what is the mild treatment regimen for LP
- cortisone 5% ointment
- triamcinolone 0.1% ointment
what is the moderate treatment regimen for LP
- cortisone 10% ointment
- fluocinonide gel 0.05%
- dexamethasone 0.05% ointment
what is the potent treatment regimen for LP
- clobetasol 0.05% ointment/gel
- halobetasol 0.05% ointment
what is the difference between steroid carriers and bleaching trays
need to border mold the impressions so tray extends to mucobuccal folds with steroid carriers
what is the treatment regimen for intra lesion steroid injections for LP
- 12 mg/week dexamethasone for 8 weeks
- 5-10 mg/wek triamcinolone PRN
what is the treatment regimen for systemic steroids with LP
- prednisone 2-3 weeks
- loading dose 0.5-1mg/kg/day (40-80 mg/qd)
- need tapering down regimen
what is the treatment regimen for methotrexate
- 10-20 mg once weekly for 4-12 weeks
what other medications are used to treat LP
- hydroxychloroquine (plaquenil)
- thalidomide
- calcineurin inhibitors
- dapsone
what is the issue with thalidomide
- bad history when used in pregnancy for anxiety, morning sickness headache
- thalidomide babies had lack of appendage development or other aplasias such as ears or malformed kidneys
what is the contemporary use for thalidomide
inflammatory mucocutaneous diseases
what is hydroxycholoroquine used for
disease modifying anti RA drug (DMARD), anti malarial, anti COVID
- relieve inflammation, swelling, stiffness and joint pain
what do calcineurin inhibitors do
- anti inflammatory medication primarily used for anti graft rejection
- pimecrolimus cream
- tacrolimus ointment
- psychotic and renal side effects when used systemically
what is dapsone
- an antibiotic with anti inflammatory properties
- can block multiple PGEs and leukotrienes thereby blocking their inflammatory effects
- potential risk of renal vasculitis
what is the risk for untreated LP
- malignant potential risk is 0.1-0.2%
which types of LP have the greatest risk of transforming to malignant
erosive and ulcerative conditions
what are the 3 types of aphthous stomatitis
- minor
- major
- herpetiform
what is the prevalence of aphthous stomatitis
affects 18-27% of the population
- prevalence is about 20%
what is the etiology of aphthous stomatitis
unknown
- no viral or infectious agent identified
- probbaly is focal immunodysfunction but mechanism is undetermined
- HLA subtype susceptibility is a factor
what are the triggers for apthous stomatitis
stress/anxiety, hormonal changes, dietary factors, trauma
what are human leukocyte antigens and what do they do
a system or complex of genes on chromosome 6 in humans which encode cell surface proteins responsible for regulation of the immune system
HLA subtype allele mutations permit:
dysregulation of the immune system taht affects mucosa and cutaneous tissues and cause outbreaks of aphthous stomatitis
in aphthous stomatitis alterations in mucosal membrane barrier permeability may be a factor because of co morbidity associations with:
- HIV/AIDS
- bone marrow suppression
- neutropenia
- gluten sensitivty
- Chron’s disease
- ulcerative colitis
- food allergy
- behcet disease
- dietary deficiencies such as iron, zinc and vitamin B12
what is the clinical description of aphthous stomatitis ulcers
- recurrent, self limiting, painful ulcers
- usually restricted to nonkeratinized oral and pharyngeal mucosa- not hard palate or attached gingiva
- well demarcated ulcers with yellow fibrinous base and erythematous halo
describe aphthous minor and when does healing occur
- most common subtype
- single but more often multiple
- less than 1cm in diameter
- oval to round shape
- healing within 7-14 days
describe ahphtous stomatitis major and what is its other name
- sutton disease
- 1cm or greater
- single or less commonly several
- deep
- to ragged edges with elevated edematous margin
- may persist for several weeks to months
- often heal with scarring
describe herpetiform aphthous stomatitis
- least common variant
- grouped superficial ulcers 1-2mm diameter
- crops of 10-100 lesions
- lesions coalesce
- in nonkeratinizaed and keratinized tissues
- healing within 7-14 days
- no etiologic role for herpes simplex virus
what is the dx for aphthous stomatitis
- usually has diagnostic clinical appearance of focal, well- defined ulcers involving non keratinized mucosa
- history helpful; a recurrent process
- positive family history
what is the DDX for aphthous stomatitis
- traumatic ulcer
- chancre
- recurrent intraoral herpes simplex virus HSV-1
- cyclic neutropenia
what is the treatment for aphthous stomatitis
- symptomatic therapy
- systemic causative factors should be addressed
- tetracycline based oral rinses may be helpful
- corticosteroid therapy- most rational and most consistently effective
- topical corticosteroids as gels, creams or ointment 4-6 times/ day to early lesions
- intralesional corticosteroid injections
- short duration systemic corticosteroids ( low to moderate doses)
- other immunomodulating drugs may be helpful
- colchicine sometimes beneficial
- thalidomide treatment
what immunomodulating drugs are helpful in aphthous stomatitis lesions
- dapsone
- hydroxychloroquine
- topical tacrolimus
- amelexanox
what dosage of colchicine for aphthous stomatitis
0.6-1.2mg/day
which form of aphthous stomatitis is more common recurrent form
minor
how often do minor aphthous stomatitis lesions appear
episodic, 1-4 episodes/year
- few lesions, usually minor or herpetiform
how often do major aphthous sotmatitis lesions appear
almost continuous ulcerations; disabling large or severe lesions
what is the difference in AIDS patients with aphthous stomatitis
lesions are more severe and may occur on any oral surface
