Oral Lichen Planus

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  • Oral lichen planus (OLP) is the oral presentation of lichen planus
  • Lichen planus is a chronic inflammatory and immune-mediated disease that affects the skin, nails, hair, and mucous membranes
  • Oral lichen planus may occur on its own or in combination with lichen planus of the skin, nails or genitals

Epidemiology[edit | edit source]

  • Lichen planus affects 1-2% of the population [1]
  • Oral lichen planus affects around 2% of the population[2]
  • Typically presents at 30-60 years of age [1] [2]
    • Some studies suggest that cutaneous lichen planus is more common in men but oral lichen planus is more common in women
  • Oral lichen planus is rare in children

Clinical Features[edit | edit source]

  • Lichen planus can be characterised as cutaneous or mucosal
    • Cutaneous lichen planus can affect the skin, scalp, and nails
    • Mucosal lichen planus can affect the whole of the gastrointestinal tract, larynx, genitals, peritoneum, nasal cavity, bladder and conjunctiva
  • 30-70% of those with cutaneous lichen planus have mucosal involvement [3]
  • About 50% of females with oral lichen planus were reported to have undiagnosed vulvar lichen planus [4]

Oral Presentation[edit | edit source]

  • Can affect any part of the oral cavity
  • Common sites are buccal/labial mucosa, gingivae, tongue. Palatal involvement is uncommon.[5]
  • Usually bilateral or multiple lesions
  • Often asymptomatic but can be sore if atrophic/ulcerated
  • There are six different clinical subtypes (more than one can occur at the same time)
Clinical subtypes
Type Incidence[6] Image Description
Reticular 92% Reticular Lichen Planus Series of raised, fine, radiant, white striae known as ‘Wickham striae’
Buccal mucosa is the site most commonly involved (striae are commonly bilateral and symmetrical)
Usually asymptomatic
Atrophic 44% Atrophic Lichen Planus Diffuse and red (usually with white striae radiating around the periphery of the lesion)
Attached gingiva is often involved (desquamative gingivitis)
Can be sore when in contact with certain foods
Plaque-like 36% Plaque-like Lichen Planus Homogenous white patches that resemble leukoplakia
Can be slightly elevated and smooth or may be irregular and multifocal
Common on dorsum of tongue and buccal mucosa
More common among smokers
Papular 11% Papular Lichen Planus Small white pinpoint papules ~0.5mm in size
Erosive 9% Erosive Lichen Planus Painful slow healing ulcers/erosions
Attached gingiva is often involved (desquamative gingivitis)

Can be sore when in contact with certain foods
Most common subtype for malignant change

Bullous 1% Bullous Lichen Planus Small bullae or vesicles that tend to rupture easily to leave an ulcer
Commonly site is buccal mucosa, especially in posteroinferior area adjacent to second and third molar teeth

Other manifestations[edit | edit source]

  • Appearance of cutaneous lesions can be remembered with 5 Ps:
    1. Planar
    2. Polygonal
    3. Pruritic (Koebner phenomenon) - also painful when scratched
    4. Purple
    5. Papular
  • Tend to occur in skin screases
  • Nail involvement → vertical ridges and can cause destruction
  • Can cause alopecia if occurs on the scalp
  • Vulval and glans penis involvement appear similar to oral lesions

Differential Diagnosis[edit | edit source]

Aetiology and Pathogenesis[edit | edit source]

  • Cause is largely unknown
  • Can be associated with hepatitis C [7]
  • Grinspan syndrome is the triad of hypertension, diabetes and oral lichen planus (unclear whether this is a separate entity or in fact drug induced lichenoid reaction secondary to the drugs used to treat hypertension and diabetes) [8]
  • Pathogenesis
    • Basal cells are prime target of destruction
    • Mediated through T cells, Langerhans cells and macrophages

Investigations[edit | edit source]

Laboratory investigations[edit | edit source]

  • Blood tests are not routinely indicated but may be needed to rule out differentials
  • Some suggest a lower threshold to screen for hepatitis C if patients demonstrate other risks

Histopahtology[edit | edit source]

Histopathology of lichen planus
  • A Biopsy is important to exclude other mimics and to identify possible dysplasia
  • Common histologic findings of oral LP include:
    1. Parakeratosis and slight acanthosis of the epithelium
    2. Saw-toothed rete ridges
    3. Liquefaction (hydropic) degeneration of the basal layer with apoptotic keratinocytes (referred to as Civatte, colloid, hyaline, or cytoid bodies)
    4. An amorphous band of eosinophilic material at the basement membrane composed of fibrin or fibrinogen
    5. A lichenoid (band-like) lymphocytic infiltrate immediately subjacent to the epithelium

Other[edit | edit source]

  • Smears and swabs for mycology may be helpful in some instances as lesions may be superinfected with candidosis (especially when treated with topical corticosteroid therapy)[9]
  • Clinical photographs may be helpful for monitoring

Management[edit | edit source]

Asymptomatic non ulcerative lichen planus[edit | edit source]

  • Explanation of the nature of the condition
  • Advice on avoidance of risk factors (tobacco and alcohol)
  • Empirical dietary advice regarding intake of fresh fruit and vegetables
  • Reassurance and referral back to the GDP or other appropriate clinician for monitoring

Symptomatic non ulcerative lichen planus[edit | edit source]

  • Topical anaesthetic and /or barrier agents for symptomatic relief of pain eg: Benzydamine hydrochloride (0.15%) spray or mouthrinse
  • Alternatively, it may be appropriate for the patient to apply 2% lidocaine gel to painful areas
  • Some patients may gain benefit from antiseptic mouthwashes such as chlorhexidine gluconate
  • Following clinical improvement, the patient should be referred back to primary care for monitoring, as above

Atrophic/Erosive lichen planus[edit | edit source]

  • Topical corticosteroid preparations (treatment dosage and duration should be titrated according to patient need):
    • Soluble prednisolone tablets, 5mg dissolved in 15ml of water and used as a mouthrinse 3-4 times daily
    • Betamethasone sodium phosphate (500mcg dissolved in 10-15ml of water) used as a mouthrinse up to 4 times daily
    • Fluticasone propionate spray (50mcg per puff), directed to affected areas up to 3-4 times daily
    • Beclometasone spray (100mcg per puff), sprayed 3-4 times daily on affected sites
    • Clobetasol ointment (0.05%) applied to painful areas 3-4 times daily
    • Fluticasone cream (0.05%) applied to painful sites 3-4 times daily
  • Appropriate topical antifungals if indicated
  • Ensure good oral hygiene
  • Counselling re: tobacco/alcohol

Severe, symptomatic atrophic/ulcerative oral lichen planus, unresponsive to topical measures[edit | edit source]

  • Consider referral to oral medicine service
  • Systemic steroids (prednisolone) - short reducing dose
  • Followed by maintenance with topical corticosteroids
  • Antifungals if appropriate
  • Counselling re: tobacco/alcohol

Recalcitrant oral lichen planus[edit | edit source]

  • Refer to oral medicine service
  • May require steroids +/- Azathioprine
  • Topical ciclosporin (100mg/ml) as a mouthwash BD - may need to check blood levels
  • Topical tacrolimus (contraindicated if evidence of epithelial dysplasia)

Prognosis and Complications[edit | edit source]

  • Oral lichen planus persists for years
  • ~1.5% risk of malignant transformation [10]
  • Lichen planus associated oral squamous cell carcinoma is associated with improved survival but increased risk of recurrence [11]

Follow-up[edit | edit source]

  • Mild → yearly review (suitable for primary care with referral if any concerns)
  • More severe/ atrophic/erosive → 6 monthly reviews
  • Dysplasia on biopsy → 3 monthly reviews

References[edit | edit source]

  1. 1.0 1.1 Le Cleach L, Chosidow O. Lichen planus. New England Journal of Medicine. 2012 Feb 23;366(8):723-32.
  2. 2.0 2.1 Eisen D. The clinical features, malignant potential, and systemic associations of oral lichen planus: a study of 723 patients. Journal of the American Academy of Dermatology. 2002 Feb 1;46(2):207-14.
  3. Wagner G, Rose C, Sachse MM. Clinical variants of lichen planus. JDDG: Journal der Deutschen Dermatologischen Gesellschaft. 2013 Apr;11(4):309-19.
  4. Le Cleach L, Chosidow O. Lichen planus. New England Journal of Medicine. 2012 Feb 23;366(8):723-32.
  5. Jungell P. Oral lichen planus: a review. International journal of oral and maxillofacial surgery. 1991 Jun 1;20(3):129-35.
  6. Thorn JJ, Holmstrup P, Rindum J, Pindborg JJ. Course of various clinical forms of oral lichen planus. A prospective follow‐up study of 611 patients. Journal of Oral Pathology & Medicine. 1988 May;17(5):213-8.
  7. Alaizari NA, Al‐Maweri SA, Al‐Shamiri HM, Tarakji B, Shugaa‐Addin B. Hepatitis C virus infections in oral lichen planus: a systematic review and meta‐analysis. Australian dental journal. 2016 Sep;61(3):282-7.
  8. Lamey PJ, Gibson J, Barclay SC, Miller S. Grinspan's syndrome: a drug-induced phenomenon?. Oral surgery, oral medicine, oral pathology. 1990 Aug 1;70(2):184-5.
  9. Jainkittivong A, Kuvatanasuchati J, Pipattanagovit P, Sinheng W. Candida in oral lichen planus patients undergoing topical steroid therapy. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology. 2007 Jul 1;104(1):61-6.
  10. Giuliani M, Troiano G, Cordaro M, Corsalini M, Gioco G, Lo Muzio L, Pignatelli P, Lajolo C. Rate of malignant transformation of oral lichen planus: A systematic review. Oral diseases. 2019 Apr;25(3):693-709.
  11. Best DL, Herzog C, Powell C, Braun T, Ward BB, Moe J. Oral Lichen Planus-Associated Oral Cavity Squamous Cell Carcinoma Is Associated With Improved Survival and Increased Risk of Recurrence. Journal of Oral and Maxillofacial Surgery. 2020 Jul 1;78(7):1193-202.