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)
Type | Incidence[6] | Image | Description |
---|---|---|---|
Reticular | 92% | 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% | 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% | 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% | Small white pinpoint papules ~0.5mm in size | |
Erosive | 9% | Painful slow healing ulcers/erosions Attached gingiva is often involved (desquamative gingivitis) Can be sore when in contact with certain foods | |
Bullous | 1% | 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:
- Planar
- Polygonal
- Pruritic (Koebner phenomenon) - also painful when scratched
- Purple
- 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]
- Lichenoid reaction
- Oral squamous cell carcinoma
- Leukoplakia
- Leukoedema
- Oral candidiasis
- Graft-versus-host disease
- Vesiculobullous disorders
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]
- A Biopsy is important to exclude other mimics and to identify possible dysplasia
- Common histologic findings of oral LP include:
- Parakeratosis and slight acanthosis of the epithelium
- Saw-toothed rete ridges
- Liquefaction (hydropic) degeneration of the basal layer with apoptotic keratinocytes (referred to as Civatte, colloid, hyaline, or cytoid bodies)
- An amorphous band of eosinophilic material at the basement membrane composed of fibrin or fibrinogen
- 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]
- ↑ 1.0 1.1 Le Cleach L, Chosidow O. Lichen planus. New England Journal of Medicine. 2012 Feb 23;366(8):723-32.
- ↑ 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.
- ↑ Wagner G, Rose C, Sachse MM. Clinical variants of lichen planus. JDDG: Journal der Deutschen Dermatologischen Gesellschaft. 2013 Apr;11(4):309-19.
- ↑ Le Cleach L, Chosidow O. Lichen planus. New England Journal of Medicine. 2012 Feb 23;366(8):723-32.
- ↑ Jungell P. Oral lichen planus: a review. International journal of oral and maxillofacial surgery. 1991 Jun 1;20(3):129-35.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.