W7 - Lichen Planus - Thomson Flashcards
2 classifications of specific pattern white lesions that cannot be scraped off
Oral Lichenoid reactions
Lupus erythematous
What are 4 oral lichenoid reactions
- Oral Lichen planus
- Oral lichen planus associated with underlying disease (diabetes, hep c)
- Lichenoid contact reactions (LCR)
- Drug induced lichenoid reactions (DILR)
Lichen Planus
Oral lichenoid contact reaction
(notice proximity to amalgam)
Oral lichenoid reaction (contact)
What is lichen planus?
Chronic inflammatory disease affecting skin and mucous membrane
How does lichen planus appear clinically? (6)
“lace-like”
Papular
plaque-like
erosive
atrophic
bullous
How does lichen planus appear on the skin? (+location)
Violaceous, flat-topped papules
- ankles
- Wrists
- genitalia
-Facial skin is spared
What is the Koebner phenomenon
The appearance of Whickham’s Striae (lace-like appearance) of lichen planus skin lesions
- appears when you scrape across the skin
- uncomfortable for patients
Whickham’s Striae
Lichen Planus appearing on skin
- wrist
labial lichen planus
Rarely affected compared to oral mucosa
Can be confused with actinic cheilitis
What are the three types here
Papular
Reticular
Erosive-ulcerative
What type of LP
Erosive-ulcerative lingual LP
What is desquamative gingivitis?
How does it appear clinically?
Widespread erythematous gingiva
Blister formation
Desquamation and erosion of gingival epithelium
Desquamative gingivitis
Desquamative gingivitis
Common conditions that can lead to desquamative gingivitis (6)
Lichen planus
Mucous membrane pemphigoid
Bullous pemphigoid
Pemphigus vulgaris
Paraneoplastic pemphigus
Dermatitis hepetiformis
Pathogenesis of Lichen Planus
T-cell mediated autoimmune disease
- CD8 T-cells trigger apoptosis of basal keratinocytes in oral epithelium in response to unknown endogenous antigen or known exogenous antigen
What virus may be an aetiological factor in OLP
Hep C (HCV)
Essential Features for histopathological diagnosis of OLP (3)
Liequefaction Degeneration in basal cell layer (dead cells)
Well-defined band of T cells in superficial connective tissues
Absence of dysplasia
Spaces - Liquefaction degeneration
Blue cells - T lymphocytes
Arrow - Civatte body (dead epithelial cell)
Differential diagnoses of OLP
Exam question
Frictional keratosis
Oral lichenoid reaction
Leukoplakia
Lupus erythmatosus
Pemphigus
Mucus membrane pemphigoid
Erythematous candidiasis
Pathognomonic clinical appearance of OLP
Interlacing white reticular striae on bilateral posterior buccal mucosa
How to differentiate OLP from lichenoid drug reaction
Drug reaction will be unilateral and accompanied by history of using a new drug
- Diagnose by removing pt from drug observe the reaction resolve
What drugs can cause lichenoid drug reactions
“Anti-things”
- Anti-hypertensives
- Anti-inflammatory (NSAID)
- Anti-diabetic
- Anti-thyroid
- Anti-malarials
How to differentiate OLP from vesiculo-bullous disorders (pemphigus, pemphigoid)
Pemphigus and pemphigoid are solitary erythematous lesions
no white striae
How to differentiate lupus erythematosis from OLP
Could resemble erosive LP but will be less symmetrically distributed
- LP has facial skin spared
- Lupus’ striae are more “delicate” and radiate from a central focus
Management of OLP
Patient education
Active patient monitoring
Supportive measures (elimination of provoking factors, minimize trauma to mucosa)
Supplemental measures (CHX - diluted)
What does the pt need to be educated about regarding their OLP
- It’s a chronic disorder - long term
- No treatment availble
- May require symptomatic relief
Therapeutic aims of LP management (4)
Minimize the immune-mediated inflammatory response
Avoid opportunistic infections
Keep it simple
Empirical (based on observation)
Topical “treatments” of OLP (3)
CHX - diluted
Orabase
Kenalog
What is Orabase and Kenalog?
Protective gel/paste
Makes it more comfortable for ulceration, erosions, sensitivity
Kenalog is Orabase but with corticosteroid
3 Levels of corticosteroids used in treatment of OLP
Mild - Hydrocortisone 1%
Moderate - Triamcinolone 0.02%
Potent - Clobetasol 0.05%
What may potent corticosteroids be prescribed with?
Topical antifungals
Ex. miconazole oral gel, nystatin, amphotericin
- Due to risk of candida infection with prolonged corticosteroid use
What do specialists do to treat OLP
Systemic steroids (prednisone)
Retinoids
Laser treatment
Topical calcineurin inhibitors
PUVA (UV therapy)
If you take a histopathological biopsy and see dysplasia, is it still OLP?
No - becomes OPMD
Is there risk of LP for malignant transformation
Controversial
- Risk probably <1%
- Single oral lichenoid lesions on tongue likely being dysplastic
What location of lichenoid lesions is likely actually be a dysplastic OLP
Single oral lichenoid lesions on tongue
When does OLP become clinically suspicious (could be PMD)
Atypical mucosal lesions
Resistant to tx
Heterogenous appearance (texture/color)
Persistent erosions & ulceration
What is “patch testing” used for?
Used to differentiate between idiopathic OLP and oral lichenoid contact lesions
How does non-erosive, non-symptomatic LP get managed
Follow ups
How does erosive/symptomatic LP get managed (4)
Initially, focus on eduation and elimination of precipitating or provoking factors
Make sure not dysplastic - biopsy
Topical steroids and antifungals
Follow up
