Lichen planus pemphigoides: report of a case with oral lesions

Vulvar lichen planus pemphigoides

Lichen planus pemphigoides (LPP) is a rare blistering disease with features of both lichen planus and bullous pemphigoid. LPP typically appears on the extremities and occasionally involves the oral mucosa. Herein, we describe a case of LPP of the vulva of an 80-year-old woman, an uncommon location for this disease process. This clinical scenario can be confused with a number of similarly appearing entities such as erosive vulvar lichen planus, mucous membrane pemphigoid, and erosive lichen sclerosus et atrophicus. In fact, our patient carried a diagnosis of lichen sclerosus by an outside physician for 2 years prior to being properly diagnosed and treated. A detailed discussion of the epidemiology, clinical, and pathogenesis as well as the histologic and immunofluorescence characteristics of this uncommon diagnosis is presented. Our case emphasizes the necessity of microscopic analysis to differentiate lookalike disease states when making a diagnosis and choosing the correct therapeutics.

The use of topical corticosteroides in the treatment of oral lichen planus in Spain: A national survey

Background

Explore the treatment of oral lichen planus with topical corticosteroids by the healthcare professionals in Spain.

Material and Methods

A questionnaire targeted health professionals who treat OLP, in particular maxillofacial surgeons, dermatologist and dentist. The dissemination of the questionnaires was conducted through professional associations and dental and medical societies. The questionnaire was previously evaluated by means of a cognitive pre-test procedure to ensure that the questions were opportune and appropriate, understandable and acceptable among the professionals.

Results

Of the 890 questionnaires sent a total of 190 questionnaires were answered by 90 dentists, 60 dermatol gists and 40 by maxillofacial surgeons. The most frequent treatment was 0.1% triamcinolone acetonide in orobase 3 times a day. The effectiveness of the topical corticosteroid treatment was 6.68 (SD= 2.26) in a scale of 1 to 10. The 30% of the dentists and 10.49% of maxillofacial surgeons combined treatment with other drugs. The most frequent one (80%) was nystatin (100,000 IU per millimetre). Dermatologists did not use other treatments in combination with corticosteroids.

Conclusions

There is a need for national guidelines in treatment for oral lichen planus (treatment criteria, drug, dose, treatment time and method of application of corticosteroid) that can be applied by all professionals who treat this disease.

Key words:Oral lichen planus, topical corticosteroids, triamcinolone acetonide, questionnaire.

Clinical and immunopathologic findings in oral lichen planus pemphigoides

Lichen planus pemphigoides (LPP) is a rare, acquired, immunobullous disorder of skin that occasionally involves oral mucous membranes. Clinical, histologic, and immunopathologic findings of the oral manifestations of LPP are described. Clinical features are lichenoid striae, erosions, and ulcerations involving gingiva and buccal mucosae. Histopathologic features are similar to those of ora lichen planus. Direct immunofluorescence demonstrates linear deposits of immunoglobulin G and complement component C3 along the basement membrane with fibrillar deposits of fibrin at the epithelial/lamina propria junction. Fluorescence overlay antigen mapping and laser scanning confocal microscopy of the biopsy specimen exhibits colocalization of in situ antibodies with beta4 integrin, a marker of the keratinocyte basal plasma membrane and upper lamina lucida, consistent with the location of the bullous pemphigoid antigens. This case report describes a case of LPP that presented exclusively as an oral condition. Lichen planus pemphigoides should be considered in the clinical differential diagnosis of vesiculoerosive oral mucosal diseases.

Lichen planus pemphigoides is a heterogeneous disease: a report of five cases studied by immunoelectron microscopy

Lichen planus pemphigoides (LPP) is a rare and controversial disease. It is characterized by bullae arising on lichen planus papules and on uninvolved skin, subepidermal bullae in histology, and linear deposits of IgG and C3 along the basal membrane zone on immunofluorescence of peribullous skin. Our goal was to identify the localization of the target antigen in cases of LPP. Five patients diagnosed with LPP on clinical, histological and immunofluorescence criteria were explored by immunoelectron microscopy and immunoblot. Our results show that the target antigen in LPP is not unique. The localization of the immune deposits was consistent with a diagnosis of bullous pemphigoid in two cases, of cicatricial pemphigoid in two cases and of epidermolysis bullosa acquisita in one case. Our study supports the view that LPP is a heterogeneous condition in which lichen planus may induce different subepidermal acquired bullous dermatoses.

Update on oral lichen planus: etiopathogenesis and management

Lichen planus (LP) is a relatively common disorder of the stratified squamous epithelia, which is, in many ways, an enigma. This paper is the consensus outcome of a workshop held in Switzerland in 1995, involving a selection of clinicians and scientists with an interest in the condition and its management. The oral (OLP) eruptions usually have a distinct clinical morphology and characteristic distribution, but OLP may also present a confusing array of patterns and forms, and other disorders may clinically simulate OLP. Lesions may affect other mucosae and/or skin. Lichen planus is probably of multifactorial origin, sometimes induced by drugs or dental materials, often idiopathic, and with an immunopathogenesis involving T-cells in particular. The etiopathogenesis appears to be complex, with interactions between and among genetic, environmental, and lifestyle factors, but much has now been clarified about the mechanisms involved, and interesting new associations, such as with liver disease, have emerged. The management of lichen planus is still not totally satisfactory, and there is as yet no definitive treatment, but there have been advances in the control of the condition. There is no curative treatment available; immunomodulation, however, can control the condition. Based on the observed increased risk of malignant development, OLP patients should be offered regular follow-up examination from two to four times annually and asked to report any changes in their lesions and/or symptoms. Follow-up may be particularly important in patients with atrophic/ulcerative/erosive affections of the tongue, the gingiva, or the buccal mucosa. Much more research is required into the genetic and environmental aspects of lichen planus, into the premalignant potential, and into the possible associations with chronic liver, and other disorders. More clinical studies are required into the possible efficacy of immunomodulatory drugs such as pentoxifylline and thalidomide.

Oral and cutaneous lichen planus pemphigoides

Lichen planus pemphigoides is a rare bullous disorder characterized by tense bullae on lichen planus lesions and on clinically uninvolved skin. A diagnosis of lichen planus pemphigoides is made on the basis of clinical, histologic, and immunopathologic evaluation. We describe a patient who had lichen planus pemphigoides of the skin and oral mucosa and briefly review the literature on this uncommon entity.

Lichen planus

Lichen planus, a papulosquamous disease, in its classical presentation is characterized by pruritic violaceous papules most commonly on the extremities of middle-aged adults. It may or may not be accompanied by oral and genital mucous membrane involvement. Its course is generally self-limited for a period of several months to years, but it may last indefinitely. There are many clinical variants described, ranging from lichenoid drug eruptions to association with other diseases such as diabetes mellitus, autoimmune disease, and the graft-versus-host reaction. The relationship of these, if any, to classical lichen planus is questionable. Multiple therapeutic options exist including corticosteroids, retinoids, griseofulvin, PUVA, and cyclosporine.

White plaque of the dorsal tongue

A case of oral lichen planus has been discussed. The causes, associated conditions, laboratory tests, and treatment were addressed. The use of cyanoacrylate "super glue" may have acted as a contactant and promoted the patient's localized lichenoid process. No additional treatment was provided other than confirmation of clinical suspicions. The most important factor was ruling out the possibility of a dysplastic or a malignant process. Should the patient become symptomatic, the treatment would probably start out with kaolin and pectin (Kaopectate) lidocaine/benadryl rinses. Should supportive therapy fail, alternative regimens including topical to systemic corticosteroids would be considered.