Inflammatory diseases of the mucous membranes. Part 2. Immunopathologic ulcerative and desquamative diseases

Bullous and desquamative diseases of the oral mucosa are not common, with the exception of ulcerative lichen planus. All produce mild to severe mucosal pain and some can be life-threatening. Recent studies have helped elucidate the pathogenesis of immunopathologic diseases, although the precise etiology for most of them remains unknown. Minor and major aphthae, lichen planus, pemphigoid, pemphigus and erythema multiforme are discussed.

[The efficacy of cyclosporin for topical use in oral lichen planus]

Oral lichen planus is a disease characterized by long symptomatic phases unresponsive to the usual therapy. Many groups have used different drugs in the treatment of lichen planus: topically applied retinoic acid, temarotene, antimycotic agents corticosteroids and immunosuppressive agents, with unsatisfactory results. Recently it has been suggested that topical cyclosporine might improve the lesions of oral lichen planus. The aim of this study was to evaluate the usefulness of this therapy in our patients. Fourteen patients, 6 males and 8 females, mean age 47 years, with oral lichen planus were enrolled in the study. All the patients were instructed to swish 5 ml of solution (500 mg) of cyclosporine in the mouth three times a day for three months. Clinical evaluation was performed before therapy and every two weeks afterwards. At each visit serum levels of cyclosporine, creatinine, total and direct bilirubin and complete blood count were performed. No side effects or blood test alterations were detected in any patient and cyclosporine serum level was always undetectable. Symptoms and oral lesions had a beneficial effect already after one month of therapy. Our results confirm that cyclosporine is useful in the treatment of oral lichen planus.

Immunomodulation by levamisole in patients with recurrent aphthous ulcers or oral lichen planus

The purpose of this study was to evaluate the effect of levamisole on the immune system of patients with recurrent aphthous ulcers (RAU) or oral lichen planus (OLP) in an open trial. Lymphocyte subsets, serum immunoglobulins, and circulating immune complexes (CIC) in patients with RAU or OLP and in normal control subjects were determined by an indirect immunofluorescence (IIF) technique with monoclonal anti-lymphocyte antibodies, by single radial immunodiffusion, and by precipitation with 3% polyethylene glycol, respectively. In addition, the anti-nuclear antibodies (ANA) and anti-basal cell antibodies (anti-BCA) in sera were detected by an IIF technique. We found a significant improvement in clinical symptoms and normalization of the decreased CD4/CD8 ratio in RAU patients after levamisole treatment. Moreover, the decreased CD4/CD8 ratio, which persisted until the remission stage in the untreated RAU patients, reverted to normal in the active late stage in the levamisole-treated patients. This reversion of aberrant cellular immunity in an earlier stage of the ulcer cycle may explain why RAU patients experience symptom improvement after levamisole treatment. Although RAU patients treated with levamisole for 1 to 3 or 4 months still had higher than normal levels of CIC and serum immunoglobulins, the levels of their IgA and IgM returned to normal values after 4 months of levamisole treatment. The serum ANA detected in 6 patients with RAU and 3 patients with erosive OLP disappeared after 1-22 months of levamisole treatment. The disappearance of serum anti-BCA was also observed in 50% of the anti-BCA-positive patients with erosive OLP after 3-13 months of levamisole treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Oral lichen planus. An evolutive clinical and histological study of 45 patients followed up on for five years

A study is made of 45 patients clinically and histologically diagnosed of oral lichen planus, and followed up on for 5 years. The course of the disease was monitored after three months and one, two and five years. The patients were classified in terms of lesion evolution (healed, improved, stationary or worse). Two evolutive groups were established for statistical purposes: (a) favorable (healed or improved lesions) and unfavorable cases (stationary or worsened oral lesions); and (b) healed and non-healed cases. Statistical correlations were established between these evolutive groups and different clinical and histological parameters, in an attempt to identify parameters of predictive value in the course of the disease. No statistically significant results were obtained, with the exception of inflammatory infiltrate. Thus, the depth of this infiltrate was found to be greater in patients with an unfavorable evolution (p = 0.02) than in those with a favorable course. Likewise, the inflammatory infiltrate was greater in non-healed than in healed cases.

Successful topical treatment of oral lichen planus and leukoplakias with fenretinide (4-HPR)

Eight patients with diffuse (non-operable) pre-cancerous lesions (oral lichen or leukoplakias) were treated with fenretinidec (4-HPR) applied topically twice daily. After one month of therapy two patients had complete remission and the other six had a greater than 75% response. 4-HPR was well tolerated, and no local or distant side effects were observed. Topical treatment may be combined with oral administration at lower doses to obtain therapeutic results with less toxicity than observed with oral administration alone. A study to further evaluate the efficacy of topical treatment is in progress at our institute.

The treatment of oral lichen planus

Lichen planus is a common oral dermatosis and it is one frequently encountered by oral surgeons. Lichen planus can be very difficult to treat, particularly when symptomatic in its erosive and ulcerated forms. This article describes several treatment modalities in the control of oral lichen planus including steroids, griseofulvin, vitamin A, cyclosporine, surgical excision, et al. Other features included consist of proper biopsy site selection, the need for annual re-examination, lichen planus's malignant potential, and when "not to treat."