Oral Lichen planus

Oral Lichen planus

1. Characteristics

   • Women 40-50 yrs
   • Prevelance
     • 1-2%
   • Spontaneous improvements & exacerbations
     • Cyclic course
   • Bilateral & usually symmetrical
   • Multifocal lesion
   • Pathogenesis
     • T cell mediated
       • Cytotoxic CD8 T cells
         • Triggers apoptosis of oral epithelium cells
   • Diagnosis
     • LFTS (detect Hep C)
     • Biopsy
       • DIF
       • Histopathology
         • Hyperkeratosis
         • No dysplasia
         • Apoptotic cells called civatte bodies
         • Band like inflammatory infiltrate mainly composed of T cells
   • Malignant transformation
     • To SCC
     • 1% over 5 years
   • Chronic condition

2. Types

   • White
     • Papular
       • Diff diagnosis
         • Fordoyce granules
     • Reticular
       • Diff diagnosis
         • Geographic stomatitis
     • Plaque
       • Diff diagnosis
         • Proliferative verrucous leukoplakia
         • Leukoplakia
   • Red
     • Erosive
       • Diff.diagnosis
         • Bullous disorder
       • Assoc. with Hep C
         • Hep C infection -> chronic liver disease -> cirrhosis -> liver cancer
         • Epidemiological evidence
     • Atrophic
       • Involves gingiva & tongue
         • Desquamative gingivitis

3. Differential diagnosis

   • Oral lichenoid reactions
     • Lichenoid contact lesions
       • Amalgam, nickel, acrylic, gold
       • Appearance
         • Unilateral
         • Topographical relationship to cause
       • Remove cause e.g. amalgam filling
         • Consider patch testing
       • Type 4 hypersensitvity reaction
     • Lichenoid drug reactions
       • Beta Blockers
       • NSAIDS
       • Penicillamine
     • GVHD
       • Bilateral
   • Diagnosing
     • Mostly unilateral, local lesions
       • OLCL
         • Biopsy for H&E
         • Patch tests for dental materials
       • DLE
         • Biopsy for H&E
         • Anti Ro antibodies
         • Anti DNA antibodies
         • ANA
         • Referral to dermatology
       • OLDR
         • Biopsy for H&E
         • Speak to GP
     • Mostly bilateral & widespread
       • SLE
         • Biopsy for H&E
         • FBC
         • ANA
         • Ro antibodies
         • Anti DNA antibodies
         • Consider referral to haemotology
       • PNP
         • Biopsy for H&E + DIF
         • ELISA for DSG1
       • GVHD
         • Biopsy for H&E + DIF
   • Lupus Erythematosus
     • DLE
     • SLE
   • Lichen Planus pemphigoides

4. Treatment

   • 3rd line
     • Systemic steroids
       • Prednisolone (+ Azothioprine)
   • For atrophic/erosive or Symptomatic
   • 2nd line
     • Topical Tacrolimus
   • 1st line
     • Topical Steroids
       • Clobetasol in Orabase

5. Manifestations

   • Oral
     • 50% with LP have oral lesions
     • Just oral is more common than full manifestations
     • Common sites
       • Most common
         • Posterior buccal mucosa
       • Gingiva
       • Labial mucosa
       • Tongue
     • Rare sites
       • FOM
       • Upper lip
       • Palate
   • Other muco-cutaneous
     • Skin
       • 44% get them
       • After months of oral lesions
       • Appears as small, flat, red/purple papules
       • Itchy
     • Scalp
     • Nails
     • Genitals
       • Malignant transformation possible
       • Most frequent extra-oral site