Number V Oral lichen planus: clinical features and management

Multiple masses on the tongue of a patient with generalized mucocutaneous lesions

Luca Pastore and colleagues discuss the differential diagnosis and management of a 62-year-old man who presented with a 6-cm fungating mass on the dorsum of the tongue.

The reported prevalence of oral lichen planus: a review and critique

OBJECTIVE

To examine all studies reporting prevalences of oral lichen planus (OLP) for epidemiological validity and to extract prevalence data from the valid papers.

DESIGN

Computer based literature searches were carried out using the MeSH headings 'lichen planus, oral and (prevalence or incidence)' and were supplemented by manual searching.

MAIN OUTCOME MEASURES

Each paper was examined for five criteria: clinic-based or population study, adequate demographic description (by sex and age group) of the population, adequate demographic description of the sample (if the population was sampled), adequate demographic description of the OLP cases identified, and histological confirmation of the clinical diagnosis.

RESULTS

Forty-five relevant papers were identified, 21 clinic-based and 24 population studies. All but one of the population studies was deficient. One study, while having some defects, was probably sufficiently valid to permit the findings to be regarded as useful. An overall age-standardized prevalence of 1.27% (0.96% in men and 1.57% in women) can be calculated from this study.

CONCLUSIONS

There appears to be only one usable prevalence study of OLP. Other large-scale studies are required in other populations. Such studies need to distinguish between OLP and lichenoid reactions.

A case of vulvovaginal gingival lichen planus in association with Good's syndrome

Vulvovaginal gingival lichen planus (VVG LP) is a distinct variant of LP frequently associated with mucocutaneous scarring and vaginal stricture formation. Good's Syndrome (thymoma with hypogammaglobulinemia) is a rare cause of immunodeficiency in adults. The clinical features, investigation findings, and challenges in the management of a patient presenting with VVG LP and Good's Syndrome are discussed.

Role of apoptosis in erosive and reticular oral lichen planus exhibiting variable epithelial thickness

Oral lichen planus (OLP) is a chronic inflammatory disease with different clinical types. Reticular and erosive forms are the most common. Although the cause of OLP remains speculative, many findings suggest auto-immune involvement, mediated by T lymphocytes against the basal keratinocytes. Inflammation, mechanical trauma or toxic agents can affect the epithelial homeostasia. Increased apoptosis may cause a decrease in epithelial thickness reflecting in the activity of the lesion. The objective of this study was to evaluate the occurrence of apoptosis and epithelial thickness in reticular and erosive forms of OLP. 15 samples of OLP each type (reticular and erosive) plus 10 of healthy mucosa were collected and processed. After morphometry, the apoptotic index and epitelial thickness were obtained. TUNEL and M30 CytoDEATH immunohistochemical assay were used to validate the morphologic criteria used. Apoptosis in the erosive OLP was significantly more intense than in the reticular type and both forms of OLP presented more apoptosis than the healthy oral mucosa. Healthy oral mucosa was thicker than both OLP forms and thicker in OLP reticular form than in the erosive one. The clinical differences between reticular and erosive forms of OLP are related to variations in epithelial thickness and in intensity of apoptosis.

The efficacy of aloe vera gel in the treatment of oral lichen planus: a randomized controlled trial

BACKGROUND

Oral lichen planus (OLP) is a chronic inflammatory disease that can be painful especially in the atrophic and erosive forms. Several therapies have been tried, with varying results. There is one case report in which aloe vera (AV) was used successfully in the treatment of lichen planus.

OBJECTIVES

To compare the efficacy of AV and placebo in the topical management of OLP.

METHODS

A randomized, double-blind, placebo-controlled trial was designed. Fifty-four patients were randomized into two groups to receive AV gel or placebo for 8 weeks.

RESULTS

Fifty-four consecutive patients (34 women and 20 men) participated in the study. We found erosive and ulcerative lesions in 83% and 17%, respectively. The most common site of OLP was the lower lip. Twenty-two of 27 patients treated with AV (81%) had a good response after 8 weeks of treatment, while one of 27 placebo-treated patients (4%) had a similar response (P<0.001). Furthermore, two patients treated with AV (7%) had a complete clinical remission. Burning pain completely disappeared in nine patients treated with AV (33%) and in one treated with placebo (4%) (P=0.005). Symptomatology improved by at least 50% (good response) in 17 patients treated with AV (63%) and in two treated with placebo (7%) (P<0.001). No serious side-effects were found in both groups.

CONCLUSIONS

AV gel is statistically significantly more effective than placebo in inducing clinical and symptomatological improvement of OLP. Therefore, AV gel can be considered a safe alternative treatment for patients with OLP.

Randomized trial of pimecrolimus cream versus triamcinolone acetonide paste in the treatment of oral lichen planus

BACKGROUND

Lichen planus is a common chronic inflammatory mucocutaneous disease, affecting 0.1% to 4% of the general population. There is no published randomized active control clinical trial on pimecrolimus for the treatment of oral lichen planus (OLP).

OBJECTIVE

The purpose of this study was to compare the efficacy and safety of pimecrolimus 1% cream with triamcinolone acetonide 0.1% paste in treating OLP.

METHODS

In this investigator-blinded parallel-group randomized clinical trial, 40 patients were randomly assigned in two equal groups to receive either pimecrolimus 1% cream or triamcinolone acetonide 0.1% paste 4 times daily for a total of 2 months and followed up for another 2 months. The patients were assessed for painful symptoms measured by visual analog scale, the Oral Health Impact Profile score, and objective clinical score. Nonparametric tests were used to assess the main outcomes. Intention-to-treat analysis was used.

RESULTS

Eighteen patients in pimecrolimus group and 17 patients in triamcinolone group finished the 4-month trial course. Both pimecrolimus and triamcinolone groups showed significant improvement in all measured efficacy end points throughout the visits. There was no significant difference between changes from baseline median values of pimecrolimus and triamcinolone groups after treatment termination in terms of visual analog scale score (-9.8 +/- 11.3 vs -8.4 +/- 18.3, P = .70), Oral Health Impact Profile score (-1.5 +/- 2.6 vs -1.6 +/- 2.1, P = .38), and clinical score (-0.7 +/- 0.6 vs -0.8 +/- 0.7, P = .86), respectively. Two patients in pimecrolimus group experienced prominent but transient burning sensation whereas none of the patients in triamcinolone group had any prominent adverse event (P = .24).

LIMITATIONS

Blood levels in pimecrolimus group were not measured and carcinogenicity of pimecrolimus, especially in its long-term use for OLP, is yet to be determined.

CONCLUSION

This study showed that patients with OLP may benefit from both topical pimecrolimus and triamcinolone acetonide therapy with minimal side effects. Further studies should be conducted to assess the maintenance effects and long-term safety of both drugs (Cochrane skin group identifier: CSG TrialNo. 22).

Oral mucosal disease: Lichen planus

Lichen planus (LP) is a common disorder in which auto-cytotoxic T lymphocytes trigger apoptosis of epithelial cells leading to chronic inflammation. Oral LP (OLP) can be a source of severe morbidity and has a small potential to be malignant. The diagnosis of OLP can be made from the clinical features if they are sufficiently characteristic, particularly if typical skin or other lesions are present, but biopsy is recommended to confirm the diagnosis and to exclude dysplasia and malignancy. OLP is treated with anti-inflammatory agents, mainly the topical corticosteroids, but newer agents and techniques are becoming available.

Gingival Involvement of Oral Lichen Planus

BACKGROUND

Oral lichen planus (OLP) is one of the most common oral mucosa disorders. OLP gingival involvement is very frequently observed and is characterized by a wide range of clinical appearance, symptomatology, and locations. The purpose of this study was to analyze the prevalence and clinical aspects of gingival lesions in a series of 213 patients affected by OLP.

METHODS

We analyzed the prevalence and clinical aspects (location, morphology, and symptomatology) of the gingival lesions in a total of 213 clinically and histopathologically assessed patients affected by OLP.

RESULTS

Gingival lesions were diagnosed in 38.4% of cases. White lesions were the most frequently observed in the gingiva (42.7%), followed by mixed lesions (31.7%), and red lesions (25.6%). For the three clinical forms, the most frequent gingival location was the simultaneous involvement of the attached and marginal gingiva. None of the white lesions presented symptomatology, whereas most red lesions or mixed forms presented symptoms that varied from discomfort to severe oral pain or a burning sensation.

CONCLUSIONS

Considering the high frequency of gingival involvement in OLP, the diversity of clinical manifestations, and its potential relationship with general and oral health in patients, periodontists should be familiar with the most common clinical aspects of OLP in the gingiva.

Oral lichen planus and oral lichenoid lesions: diagnostic and therapeutic considerations

Several therapeutic agents have been investigated for the treatment of oral lichen planus (OLP). Among these are corticosteroids, retinoids, cyclosporine, and phototherapy, in addition to other treatment modalities. A systematic review of clinical trials showed that particularly topical corticosteroids are often effective in the management of symptomatic OLP lichen planus. Systemic corticosteroids should be only considered for severe widespread OLP and for lichen planus involving other mucocutaneous sites. Because of the ongoing controversy in the literature about the possible premalignant character of OLP, periodic follow-up is recommended. There is a spectrum of oral lichen planus-like ("lichenoid") lesions that may confuse the differential diagnosis. These include lichenoid contact lesions, lichenoid drug reactions and lichenoid lesions of graft-versus-host disease. In regard to the approach to oral lichenoid contact lesions the value of patch testing remains controversial. Confirmation of the diagnosis of an oral lichenoid drug reaction may be difficult, since empiric withdrawal of the suspected drug and/or its substitution by an alternative agent may be complicated. Oral lichenoid lesions of graft-versus-host disease (OLL-GVHD) are recognized to have an association with malignancy. Local therapy for these lesions rests in topical agents, predominantly corticosteroids.

Familial oral lichen planus: presentation of six families

OBJECTIVE

To present a series of 13 different cases of oral lichen planus (OLP) in 6 different families.

STUDY DESIGN

From 249 lichen planus cases, we found 13 that could be considered to be family related. A study of these 13 cases of OLP was carried out across the various generations, and the means of presentation, placement, and injuries were studied, as well as signs and symptoms.

RESULTS

The predominant affectation was in the women; only 2 patients were male. The mothers showed predominance toward erythematous OLP with greater symptoms, and in their children, symptom-free white OLP was predominant.

CONCLUSIONS

It seems there may be some genetic predisposition toward OLP.