Subsets of T lymphocytes in peripheral blood of patients with oral lichen planus

Perforin expression in peripheral blood lymphocytes and skin-infiltrating cells in patients with lichen planus

BACKGROUND

Current evidence suggests that lichen planus is a T-cell-mediated autoimmune disease in which cytotoxic mechanisms have been poorly investigated.

OBJECTIVES

We investigated the expression of perforin in subpopulations of peripheral blood lymphocytes (PBL) in exacerbation and remission phases of the disease as well as in skin lesions.

METHODS

We performed a simultaneous detection of perforin (intracellular molecule) and cell surface antigens on PBL by flow cytometry, and skin lesions were investigated by immunohistochemistry.

RESULTS

The most interesting finding was a significant increase of perforin expression in cytotoxic T lymphocytes (CD3+ perforin+ cells) in the exacerbation phase of disease (P < 0.05), which was mostly located in the CD8+ subpopulation (CD8+ perforin+) (P < 0.01). Using immunohistochemistry we confirmed the infiltration of T lymphocytes in skin lesions, especially of CD4+ and CD8+ phenotypes, compared with uninvolved (P < 0.05) and healthy skin (P < 0.01). The expression of perforin was also significantly higher in lesional skin compared with nonlesional and healthy skin (P < 0.05).

CONCLUSIONS

Our results clearly show the upregulation of perforin expression in peripheral blood as well as in lesions of patients with lichen planus and therefore suggest an important role for perforin in this autoimmune disease.

Peripheral T-cell subsets in patients with reticular and atrophic-erosive oral lichen planus

OBJECTIVE

Oral lichen planus (OLP) presents with various clinical forms that can be classified into 2 major types: reticular OLP and atrophic-erosive OLP. Our objective was to investigate immunologic differences between these 2 types.

STUDY DESIGN

We investigated possible immunologic differences between 26 patients with reticular OLP and 26 patients with atrophic-erosive OLP.

RESULTS

No differences were detected in serum Ig levels or complement levels. However, the mean proportions of CD4+CD45RO+ and DR+ lymphocytes were significantly higher in patients with atrophic-erosive OLP than in patients with reticular OLP, whereas the mean proportion of CD8+CD45RA+ lymphocytes was significantly lower in patients with atrophic-erosive OLP.

CONCLUSION

These findings suggest that the 2 clinical types of OLP might have different immunopathogenic mechanisms.

Management of oral lichen planus

Lichen planus is a relatively common disorder of the stratified squamous epithelia. Most dental and medical practitioners see patients with lichen planus, but not all are recognized as having the disease. Patients with lichen planus may have concomitant involvement of the disease in multiple sites. Oral lichen planus lesions usually have a distinctive clinical morphology and characteristic distribution, but oral lichen planus may also present a confusing array of patterns and forms, and other disorders may clinically mimic oral lichen planus. The etiopathogenesis of lichen planus appears to be complex, with interactions between genetic, environmental, and lifestyle factors. Much has now been clarified about the etiopathogenic mechanisms involved and interesting new associations, such as with liver disease, have emerged. The management of lichen planus is still not totally satisfactory in all cases and there is as yet no definitive treatment that results in long term remission, but there have been advances in the control of the condition. Amongst the many treatments available, high potency topical corticosteroids remain the most reliably effective, though topical cyclosporine, topical tacrolimus, or systemic corticosteroids may be indicated in patients whose condition is unresponsive to topical corticosteroids.

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.

TCR V beta gene expression in lesional T lymphocyte cell lines in oral lichen planus

To study V beta gene expression in oral lichen planus (OLP) lesional T lymphocytes cell lines.

MATERIALS AND METHODS

Lesional T lymphocytes were isolated from eight OLP patients and cell lines established. The total RNA was extracted from these lymphocyte cell lines and reverse transcribed. cDNA was amplified by the polymerase chain reaction (PCR) using a panel of 26 V beta-specific oligonucleotide primers followed by qualitative analysis of the electrophoresed reaction products.

RESULTS

V beta 1, 2, 3, 5.1, 6.1-3, 7, 8, 9, 22, 23, and 24 were represented consistently in all of the OLP samples, V beta 11, 12, and 17 were consistently negative, while the other V beta families (V beta 4, 5.2-3, 10, 13.1, 13.2, 14, 15, 16, 18, 19, 20, and 21) were variable. V beta 22 and 23 were the most strongly expressed in all patients.

CONCLUSIONS

A limited T cell receptor (TCR) gene usage indicates a degree of oligoclonality within these lesional T lymphocyte cell lines from OLP. This implies that OLP may be an antigen-specific disease or linked to a limited number of superantigens.

Dramatic response to levamisole and low-dose prednisolone in 23 patients with oral lichen planus: a 6-year prospective follow-up study

The purpose of this prospective study was to evaluate the short-term and long-term clinical efficacy of levamisole used with low-dose prednisolone in patients with refractory oral lichen planus. Twenty-three patients with OLP who had been treated unsuccessfully with other modalities were given 150 mg/day levamisole and 15 mg/day prednisolone for 3 consecutive days each week. Twelve patients showed dramatic remission of signs and symptoms within 2 weeks, whereas 11 had partial remission. All 23 reported significant pain relief and showed no evidence of erosive oral lichen planus after 4 to 6 weeks of treatment. All 23 also remained free from symptoms for 6 to 9 months after the treatment ended. There were few side effects from this treatment besides minor skin rash, headache, and insomnia from the levamisole in three cases. We conclude that the addition of levamisole to prednisolone may produce improved results in the management of erosive oral lichen planus.

Presence of anti-basal cell antibodies in oral lichen planus

BACKGROUND

An autoimmune hypothesis for oral lichen planus (OLP) has been proposed, but no anti-basal cell antibodies (anti-BCA) have been found in the sera of patients with OLP.

OBJECTIVE

Our purpose was to test whether the negative results of anti-BCA assays in sera have been due to the insensitivity of the substrates. Rat esophagus, monkey esophagus, as well as human oral mucosa and skin were used to detect anti-BCA in sera of OLP patients.

METHODS

By indirect immunofluorescence technique, the rat esophagus was found to be the most sensitive substrate. Therefore it was used as the only substrate to test the presence of anti-epithelial cell antibodies (anti-ECA) in a large group of patients with OLP and other oral mucosal diseases or normal control subjects.

RESULTS

The results showed that anti-ECA were detected in 54% (34 of 63) of patients with OLP, 71% (15 of 21) of patients with aphthous ulcers, 29% (6 of 21) of patients with oral carcinoma, 20% (2 of 10) of patients with traumatic ulcer, and 7% (1 of 15) of patients with periodontitis but none of the healthy control subjects (n = 41). The presence of anti-BCA in OLP patients' sera was persistent and lasted for a few months or years. There was a decrease in the serum anti-BCA titers in six of eight anti-BCA-positive OLP patients after topical application of triamcinolone.

CONCLUSION

These anti-BCA that persist longer in OLP patients' sera may be autoantibodies that are raised against altered basal cell-specific antigens.

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.

Oral lichen planus. A review

Lichen planus is a mucocutaneous disease of unknown etiology which, according to current knowledge, may represent a cell-mediated immunological response to induced antigenic changes in the skin and mucosa. Oral lichen planus (OLP) is a disease of adulthood and as one of the most prevalent diseases affecting the oral mucosa it has been the subject of intensive research during recent years. Ultrastructural and immunohistochemical studies particularly dealing with the subepithelial inflammatory cell infiltrate and its relations to epithelial pathology, the basal cell region and the intraepithelial antigen presenting Langerhans' cells, have contributed vastly to our knowledge of the pathogenesis of OLP. However, the treatment of OLP still remains largely symptomatic because many as yet unknown factors, active in the disease process, still remain to be elucidated.

Cellular immunosuppression in oral lichen planus

Functions of peripheral blood lymphocytes and neutrophils from 30 oral lichen planus (OLP) patients were examined using healthy persons as controls. Two-color flow cytometry of lymphocytes revealed no proportional difference in CD3 or CD4 cells between OLP and controls. CD8CD11b (suppressor T) and CD3HLA-DR+ cell populations increased significantly in OLP when compared with controls, and CD4/CD8 cell ratio decreased in OLP. Mitogenic response of patients' CD8 and CD4Leu8- cells was similar to that in controls. However, weaker blastogenesis of CD4Leu8+ cells, the most excellent responders in T cell subsets, was observed in OLP. Serum IFN beta level in OLP (8.4 +/- 4.8 IU/ml) was significantly lower than in controls (13.7 +/- 5.0 IU/ml) whereas no difference between the two groups could be found in IFN alpha or gamma. As for in vitro cytokine production by IL-2-stimulated lymphocytes, there was no difference in GM-CSF generation between the two groups, but, IFN gamma and IL1 beta production of patients' lymphocytes was less than that in healthy donors (57.6 +/- 50.7 VS 78.7 +/- 39.6 u/ml, 152.3 +/- 93.5 VS 258.7 +/- 65.4 pg/ml, respectively). Moreover, superoxide generation of patients' neutrophils by PMA stimulation was significantly insufficient as compared with controls' (84.9 +/- 30.9 VS 110.8 +/- 24.1 pmol/min/10(4) cells). Nevertheless, natural killer cell activities of both groups distributed in the same range. These results suggest that OLP patients' lymphocyte and neutrophil functions are impaired, and that cellular immunosuppression is a pathologic characteristic of OLP.

Effect of topical cyclosporine rinse on oral lichen planus. A double-blind analysis

BACKGROUND

Oral lichen planus is a relatively common disorder of the mouth that can be debilitating. It is frequently palliated with topical or systemic corticosteroids and retinoids. These treatments require prolonged use, however, and are not always effective.

METHODS

In a double-blind trial, 16 patients with symptomatic oral lichen planus were randomly assigned to receive either topical cyclosporine or its vehicle. The patients swished and expectorated 5 ml of medication (containing 100 mg of cyclosporine per milliliter) three times daily.

RESULTS

After eight weeks, the eight recipients of cyclosporine had marked improvement in erythema (P = 0.003), erosion (P = 0.02), reticulation (presence of white lacelike lesions; P = 0.007), and pain (P = 0.002), whereas the eight recipients of vehicle had no change or minimal improvement. After a switch to cyclosporine for eight weeks, the vehicle-treated patients had improvement similar to that seen in the patients who initially received cyclosporine. There were no systemic side effects. In most cases blood cyclosporine levels were low or undertectable. Cyclosporine levels present in specimens of oral mucosa at the end of therapy four hours after the patients swished were similar to the levels previously reported in psoriatic lesions after treatment with systemic cyclosporine (14 mg per kilogram of body weight per day).

CONCLUSIONS

As a topical preparation, cyclosporine may be useful in the treatment of oral lichen planus and possibly other cutaneous disorders.

HLA-DR and DQ antigens in Chinese patients with oral lichen planus

A study of HLA-DR and DQ typing in 44 patients with oral lichen planus (OLP) (28 women and 16 men) and in 107 normal controls of both sexes was performed by using Terasaki's oriental tray. Twenty-eight patients had erosive forms of lichen planus (OLPe). Serologic typing revealed a highly significant increase of HLA-DR 9 and Te 22 antigens in the patient group. Considering our findings and those in other autoimmune diseases, it is hypothesized that OLP is a localized autoimmune disease and the HLA-DR9 in Chinese takes the place of HLA-DR3 in Caucasians in carrying the genes which predispose to the development of autoimmune disease.