Lichen planus and primary biliary cirrhosis

Exacerbations of oral lichen planus and elevated levels of aminotransferases

BACKGROUND

Liver enzymes appear to be involved in oral lichen planus (OLP), but it is not known whether the elevation develops concomitantly with exacerbations of disease. We compared the levels of serum hepatic aspartate (AST) and alanine (ALT) aminotransferases as markers of OLP exacerbation in patients with chronic hepatitis C from those with chronic liver disorders, seronegative for hepatitis C virus (HCV).

METHODS

We studied 71 patients with OLP, (48 HCV seropositive and 23 HCV seronegative with chronic liver diseases) measuring AST and ALT. Association of HCV infection status with serum aminotransferase levels in relation to several types of OLP, exacerbations, and clinical score was studied by means of logistic and linear regression (correcting for age and sex).

RESULTS

Of 476 patients screened, 71 were eligible for the study. Patients in the HCV seropositive group had more elevation of AST and ALT levels (mean level, 51.0 U/l; normal level, <45) than patients in the HCV seronegative group (mean level, 47.5 U/l). Mean serum AST and ALT exceeded the upper limit of the normal range in 33 of 48 (68.8%) in the HCV antibody-positive group and in 9 of 23 (39.5%) in the HCV antibody-negative group. Exacerbations of OLP were more frequent in the high-level AST and ALT group, while HCV status group played a minor role.

CONCLUSIONS

Among patients with OLP, mild elevation in aminotransferase levels was more common in patients infected with HCV. AST and ALT concentrations were elevated in association with exacerbation of OLP.

Hepatitis C virus-host interactions: Etiopathogenesis and therapeutic strategies

Hepatitis C virus (HCV) is a significant health problem facing the world. This virus infects more than 170 million people worldwide and is considered the major cause of both acute and chronic hepatitis. Persons become infected mainly through parenteral exposure to infected material by blood transfusions or injections with nonsterile needles. Although the sexual behavior is considered as a high risk factor for HCV infection, the transmission of HCV infection through sexual means, is less frequently. Currently, the available treatment for patients with chronic HCV infection is interferon based therapies alone or in combination with ribavirin and protease inhibitors. Although a sustained virological response of patients to the applied therapy, a great portion of patients did not show any response. HCV infection is mostly associated with progressive liver diseases including fibrosis, cirrhosis and hepatocellular carcinoma. Although the focus of many patients and clinicians is sometimes limited to that problem, the natural history of HCV infection (HCV) is also associated with the development of several extrahepatic manifestations including dermatologic, rheumatologic, neurologic, and nephrologic complications, diabetes, arterial hypertension, autoantibodies and cryglobulins. Despite the notion that HCV-mediated extrahepatic manifestations are credible, the mechanism of their modulation is not fully described in detail. Therefore, the understanding of the molecular mechanisms of HCV-induced alteration of intracellular signal transduction pathways, during the course of HCV infection, may offer novel therapeutic targets for HCV-associated both hepatic and extrahepatic manifestations. This review will elaborate the etiopathogenesis of HCV-host interactions and summarize the current knowledge of HCV-associated diseases and their possible therapeutic strategies.

Cutaneous manifestations of common liver diseases

Skin functions as a window to our overall health and a number of systemic diseases result in various cutaneous changes. Knowledge of these manifestations helps in suspecting an underlying systemic illness. Cutaneous abnormalities are quite common in patients with liver diseases and this article aims to focus on these dermatoses. Cutaneous manifestations seen in patients with liver disease though common are nonspecific. They can also be seen in patients without liver diseases and generally do not indicate about a specific underlying hepatic disorder. The presence of a constellation of signs and symptoms is more useful in pointing toward an underlying hepatobiliary condition. The commonest symptom in patients with liver disease is pruritus which is often protracted and disabling. Other common features include spider angiomas, palmar erythema, paper money skin, xanthelasmas, pigmentary changes, and nutritional deficiencies. In this article, first the common cutaneous manifestations that may be associated with liver disorders are discussed and then common liver diseases with their specific cutaneous findings are discussed. Cutaneous abnormalities may be the first clue to the underlying liver disease. Identifying them is crucial for early diagnosis and better management.

Dermatologic disorders and the liver

Chronic liver disease is associated with several cutaneous manifestations. Although many of these changes are nonspecific, some are associated with distinct liver diseases and correlate with the severity of hepatic pathology. Often the first clue to a liver disease is manifested through skin. Although cirrhosis is associated with spider nevi and palmar erythema, disorders can result in noncirrhotic cutaneous manifestations. It is important for physicians to be familiar with the spectrum of these manifestations, to recognize, help detect, and treat the underlying hepatic disease. This article reviews the medical literature and discusses the spectrum of dermatologic manifestations of liver disorders and their pathogenesis, significance, and treatment.

Dermatological manifestations in primary biliary cirrhosis patients: a case control study

OBJECTIVES

Primary biliary cirrhosis (PBC), a disease of probable autoimmune etiology that affects the small intrahepatic bile ducts of mainly middle-aged women is commonly associated with pruritus, xanthomatous lesions, and melanosis. We conducted a prospective study to systematically describe the skin disorders of a group of PBC patients.

METHODS

A prospective evaluation and analysis of dermatological manifestations including oral and genital lesions was carried out, in 49 PBC patients (45 females and 4 males). Median age 63 yr (range 35-87 yr). They were compared with 45 age and sex matched controls, selected among persons attending the dermatologic outpatient clinic.

RESULTS

A total of 330 skin disorders were found in the 49 PBC patients versus 76 in the 45 controls; 31.5% of all lesions were skin fungal infections. Of all lesions analyzed with the Bonferroni rule of multiple comparisons significantly more common in PBC patients were plantar mycoses, onychomycoses, and interdigital mycoses. Pruritus was found in 69.3% of patients versus 22.2% of controls, xerosis in 69.3%versus 2.2%, dermographism in 57.1%versus 4.4%, and melanosis in 46.9%versus 0%. In 38.7% of the PBC patients the dermatologic lesion was the presenting symptom.

CONCLUSIONS

PBC patients present with a wide variety of cutaneous manifestations varying in severity. Multiple skin fungal infections have been found even in the early stages. Since in more than one third of our PBC patients the dermatologic lesion was the presenting sign or symptom leading to diagnosis we believe that physicians should be aware so that a prompt and early diagnosis may be achieved.

Current controversies in oral lichen planus: Report of an international consensus meeting. Part 1. Viral infections and etiopathogenesis

Despite recent advances in understanding the immunopathogenesis of oral lichen planus (LP), the initial triggers of lesion formation and the essential pathogenic pathways are unknown. It is therefore not surprising that the clinical management of oral LP poses considerable difficulties to the dermatologist and the oral physician. A consensus meeting was held in France in March 2003 to discuss the most controversial aspects of oral LP. Part 1 of the meeting report focuses on (1) the relationship between oral LP and viral infection with special emphasis on hepatitis C virus (HCV), and (2) oral LP pathogenesis, in particular the immune mechanisms resulting in lymphocyte infiltration and keratinocyte apoptosis. Part 2 focuses on patient management and therapeutic approaches and includes discussion on malignant transformation of oral LP.

No association between hepatitis B or C viruses and vulval lichen planus in a UK population

The aim of the study was to investigate the prevalence of hepatitis C (HCV) antibodies, hepatitis B surface antigen (HBsAg) carriage and liver disease in 100 females with genital lichen planus (LP) in Oxfordshire. Sera were screened for HCV antibodies (AxSYM HCV 3.0 Abbott), HBV surface antigen (AxSYM HBsAg V2 Abbott), mitochrondrial and anti-smooth muscle antibodies. Liver function tests were undertaken. All sera were negative for HCV antibody and HBsAg. Transiently abnormal liver function tests (2) and liver specific antibodies (2) were detected in four patients with no underlying liver disease. We found no association between HBV or HCV and genital LP in this population.

Hepatitis C virus infection in Thai patients with oral lichen planus

OBJECTIVE

Many studies focusing on the association between hepatitis C virus (HCV) infection and oral lichen planus (OLP) have been conducted. Diversities of geographical locations could be a major factor influencing the prevalence of HCV. This study was aimed to define whether there was a relationship between the OLP and HCV infection in Thailand.

MATERIALS AND METHODS

Serum samples of 60 patients (with OLP) and 60 controls (without OLP), whose age and gender were matched, were respectively screened for anti-HCV by ELISA (third generation), and reverse transcription polymerase chain reaction (RT-PCR) for HCV-RNA.

RESULTS

We found five patients (8.33%) with OLP infected with HCV: three patients were positive for both anti-HCV and HCV-RNA; one patient was only positive for anti-HCV; and one patient was only positive for HCV-RNA; whereas all the controls were negative for both anti-HCV and HCV-RNA (P=0.029). Three of five cases of OLP with HCV infection had histories of blood transfusions over 10 years ago.

CONCLUSION

The present study reports a small, but statistically significant high prevalence of HCV infection among patients with OLP, although the underlying mechanism still remains unknown.

Oral diseases possibly associated with hepatitis C virus

Morbidity associated with hepatitis C virus (HCV) infection can involve a variety of extrahepatic conditions, including lichen planus (LP) and sialadenitis, predominantly or exclusively involving the oral region, conditions which have been largely neglected in reviews. The literature suggests that HCV-infected patients may frequently have Sjögren-like sialadenitis with mild clinical symptoms, whereas oral LP may be significantly associated with HCV infections in Southern Europe and Japan but not in Northern Europe. These geographical differences could be related to immunogenetic factors such as the HLA-DR6 allele, significantly expressed in Italian patients with OLP and HCV. Analysis of experimental data suggests that HCV could be involved in the pathogenesis of both these diseases. Moreover, parotid lymphoma may arise in patients with sialadenitis, mainly with type II cryoglobulinemia. Little attention has been paid to oral health needs in HCV-infected patients and the variable effect of interferon-alpha therapy on oral tissues. Further research is needed, because of the potentially great influence of oral diseases possibly linked to HCV on the quality of life of millions of patients.

Lichen planus and leukocytoclastic vasculitis induced by interferon alpha-2b in a subject with HCV-related chronic active hepatitis

Lichen planus (LP) has been reported in association with chronic active hepatitis, primary biliary cirrhosis and other chronic liver diseases. The occurrence of LP in persons with hepatitis C virus (HCV) was reported by Robert et al., and the possible relationship between LP and hepatitis virus has also been supported by cases of LP following hepatitis B vaccination. Exacerbation or appearance of LP during the treatment of chronic hepatitis C, lymphoproliferative diseases and melanoma with alpha-interferon (IFN-alpha) and improvement of these diseases after discontinuation of this drug indicate that IFN-alpha may possibly induce LP. We present a case of cutaneo-mucous LP in a woman with chronic active hepatitis treated with IFN-alpha and in whom local leukocytoclastic vasculitis was induced by the intradermal injection of a very low dose of IFN-alpha.

Concurrent oral lichen planus and primary sclerosing cholangitis

Four patients with concomitant oral lichen planus (OLP) and primary sclerosing cholangitis (PSC) are presented. Associations have been made between OLP and chronic liver disease, namely hepatitis C and primary biliary cirrhosis, but the aetiology and commonality between the diseases has yet to be confirmed. An immunological link is currently favoured. PSC may be a further association with OLP, possibly involving the immune system.

TT virus detection in oral lichen planus lesions

Epidemiological studies have demonstrated a correlation between oral lichen planus and different liver diseases. The new virus termed TT virus (TTV) is highly prevalent in patients with chronic hepatitis of different etiology and it may be speculated that TT virus may be involved in the pathogenesis of oral lichen planus. This study examined the presence of TT virus DNA in serum by PCR and in oral mucosa biopsies by in situ hybridization from 20 patients with oral lichen planus (13 with chronic hepatitis and seven without liver disease). Serum and oral mucosa biopsies from six patients all with chronic hepatitis with leukoplakia were also studied as controls. TT virus DNA was positive in the serum of 17/20 (85%) of the patients with oral lichen planus and in all the controls. TT virus DNA hybridization signals were detected in mucosa biopsies from all the patients with TT virus DNA in serum but in none of the three cases without this marker. The percentage of positive cells ranged from 1.6-80%. No differences were found in the percentage of positive cells between TT virus positive patients with and without oral lichen planus and there was no relationship between the number of positive cells and the intensity of the inflammatory infiltrate. In conclusion, TT virus infects oral epithelial cells but the results do not support a role for TT virus in causing oral lichen planus.

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.

An exploratory population-based case-control study of primary biliary cirrhosis

Primary biliary cirrhosis (PBC) is a disease of unknown etiology, with unexplained geographical variation. Various exposures have been suggested as triggers for disease development-possibly in susceptible individuals, but the evidence was not always well founded. We therefore conducted a population-based case-control study in Northeast England to investigate these and other exposures. All cases incident during 1993 to 1995 in a defined area of Northeast England were identified, and age- and sex-matched population controls were identified from primary care population registers. Cases and controls were sent postal self-completion questionnaires covering medical history and lifestyle. Information was received from 100 cases and 223 controls. The familial tendency of PBC was found to be less marked than has been claimed: Only weak associations were found with other autoimmune diseases. Among factors considered previously, no significant associations were found with surgical procedures, events in pregnancy, past infections, vaccinations, and medications. No significant associations were found for previously unconsidered lifestyle factors (drinking alcohol, previous pets, or stressful events), but there was an unexpected association with past smoking (ever smoked: 76% in cases vs. 57% in controls, odds ratio 2.4; smoked for 20 years or more: 64% vs. 35%, odds ratio 3.5). There were also unexpected significant associations with psoriasis (13% in cases vs. 3% in controls, odds ratio 4.6) and eczema (3% in cases vs. 11% in controls, odds ratio 0. 13). These findings merit further investigation.

Dermatologic manifestations of gastrointestinal disorders

Many disorders of the gastrointestinal tract have cutaneous manifestations. Thus, a careful examination of the skin may uncover clues to underlying diseases of the liver, gastrointestinal tract, and pancreas. This article explores the alimentary-cutaneous relationship.

Lichen sclerosus and lichen planus: a spectrum of disease? Report of two cases and review of the literature

There has long been controversy concerning the relationship between lichen planus and lichen sclerosus. Whilst these two conditions are now considered distinct, there are shared clinical and pathological features. We now describe two patients with the cutaneous involvement of both lichen planus and lichen sclerosus, presenting a review of similar reported cases and discussing the implications for pathogenesis of these two diseases. Neither lichen planus (LP) nor lichen sclerosus (LS) are uncommon yet they have only infrequently been reported as coexisting. In his original description of LS, however, Hallopeau considered it to be a variant of LP and Gougerot has also commented on a possible common pathogenesis for the two conditions. Features which tend to support such as association include the distribution of the cutaneous lesions, histopathological features such as hydropic basal cell degeneration and a band-like lymphohistiocytic infiltrate in the dermis, and the reported association with autoimmune disease. We now report two patients in whom coexistent cutaneous LS and LP was confirmed histologically.

Preliminary investigation of the association of oral lichen planus and hepatitis C

OBJECTIVE

The aim of this investigation was to determine if an association exists between hepatitis C virus and oral lichen planus.

STUDY DESIGN

Three groups of subjects were selected: 505 patients with hepatitis C virus infection (group 1), 100 patients with oral lichen planus (group 2), and a randomly selected control group (age- and gender-matched) of 100 healthy subjects (group 3). The prevalence of oral lichen planus was determined in groups 1 and 3, and the prevalence of hepatitis C virus infection was established in groups 2 and 3.

RESULTS

The prevalence of oral lichen planus was 3.36% (n = 17) in group 1 and 1% (n = 1) in the control group; the prevalence of hepatitis C virus infection was 23% (n = 23) in group 2, and 5% (n = 5) in the control group. No significant differences were observed in the incidence of oral lichen planus in group 1 between those patients who received interferon and those who did not. The 17 patients in group 1 who manifested oral lichen planus and hepatitis C virus infection simultaneously exhibited a marked tendency to have only reticular lesions (70.6%), with involvement of the buccal mucosa in 88.2% of these patients, the tongue in 29.4%, and the gingiva in 11.8%. Analyzing a randomized subgroup of 143 patients from group 1 (subgroup 1) that was matched by age and gender with groups 2 and 3, we found that the incidence of oral lichen planus in patients with hepatitis C virus infection (subgroup 1) was greater than in the control group (5.59% vs 1%), though this was not statistically significant (chi2 = 0.119; p = 0.06). In contrast, group 2 exhibited a statistically significant higher incidence of hepatitis C virus infection (23%) than the controls (5%; chi2 = 0.259, p = 0.0002).

CONCLUSIONS

The prevalence of hepatitis C virus infection in patients with oral lichen planus was greater than in the control series. In our opinion this observation warrants the investigation of potential concomitant hepatitis C virus infection in patients with oral lichen planus.

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.

Hepatitis C virus infection and lichen planus: a short review

OBJECTIVE

To review the current literature regarding the association of lichen planus (LP) and liver disease, with particular attention to the association of the oral variant of the disease with hepatitis C virus (HCV) infection.

MATERIALS AND METHODS

Available literature of the possible association of LP with systemic disorders, in particular chronic hepatic disease, has been reviewed.

RESULTS

LP is sometimes associated with infectious or autoimmune disease and/or neoplasia, however an aetiological association between LP and these disorders seems unlikely. A more consistent association exists between LP and chronic hepatic disease. The precise cause of this association is not known. However, in the last 6 years a notable association between HCV infection and LP has been observed, particularly in patients in Spain, Italy and Japan. The pathogenesis of this possible HCV-associated LP is not known, but it may involve a cell mediated response to an altered epithelial antigen.

CONCLUSION

There is now evidence to suggest a significant association between HCV infection and LP in some groups of patients.

Case report: acanthosis nigricans in association with primary biliary cirrhosis: resolution after liver transplantation

A case is described of a 58 year old Caucasian male with primary biliary cirrhosis (PBC) who first presented with acanthosis nigricans of both axillae, skin pigmentation, which was pronounced over the posterior surface of the neck, and generalized pruritus. Following orthotopic liver transplantation for progressive liver disease, the skin pigmentation, pruritus and acanthosis nigricans resolved. It is believed that this is the first reported case of acanthosis nigricans occurring in association with PBC, a phenomenon that resolved after liver transplantation.

The cutaneous manifestations of gastrointestinal disease

Specific cutaneous manifestations are found to be associated with gastrointestinal disease. A careful examination of the skin, therefore, may uncover clues to underlying diseases of the gastrointestinal tract, pancreas, and liver. This article explores the alimentary cutaneous relationship.

Lichen planus and hepatitis C virus: prevalence and clinical presentation of patients with lichen planus and hepatitis C virus infection

Although cases of lichen planus (LP) associated with hepatitis C virus (HCV) infection have been described, the association between the two diseases has not been established because the geographic origin of patients could be an important factor in HCV prevalence in patients with LP. The serum samples of 78 consecutive patients with cutaneous and/or mucous LP and 82 control patients were analysed for the presence of antibodies to HCV by enzyme-immunoassay and for the presence of antigens of HCV by two-stage polymerase chain reaction (PCR). The clinical features of patients with LP associated with HCV infection were compared with patients with LP without HCV infection. Sixteen of the 78 (20%) patients had anti-HCV antibodies. In 13 of these 16 cases (81%), HCV-RNA was detected by PCR in serum samples. In the 82 control patients, anti-HCV antibodies was observed in two (2.4%) patients. We have found a statistically significant association (P < 0.05) between erosive LP and HCV infection. We conclude that the high prevalence of HCV-RNA in patients with LP provides some evidence for the role of HCV in the pathogenesis of LP. Our results suggest an association between erosive LP and HCV infection.

Oral lichen planus and chronic liver disease: a clinical and morphometric study of the oral lesions in relation to transaminase elevation

Serum transaminase levels (serum glutamic-oxaloacetic transaminase or serum glutamic-pyruvic transaminase) were found to be altered in 40 (21.39%) of 187 patients with oral lichen planus. The patients with oral lichen planus who had altered transaminase levels were on average older than those without liver disorders and exhibited a higher percentage of erosive lesions (p < 0.05) and tongue involvement. Histologically, no statistically significant differences were noted in the extension of inflammatory infiltration or in connective tissue density; nevertheless, the latter was greater in patients without altered transaminase levels. Finally, among those patients with altered liver test results and erosive lichen planus, serum glutamic-oxaloacetic transaminase and serum glutamic-pyruvic transaminase levels were found to be higher than levels in those patients without erosions. This indicates that behavior of the oral lesions is more aggressive as the degree of liver alteration increases. We emphasize that of the 40 patients with altered transaminase levels (all later proved to reflect chronic hepatitis through complementary diagnostic methods), 28 had hepatitis C virus infection.

Primary biliary cirrhosis presenting with granulomatous skin lesions

A case is described of primary biliary cirrhosis in a 59 year old woman who initially presented with a rash over her lower legs 18 months before diagnosis. Skin biopsy examination showed non-caseating granulomas of the sarcoid type. It is believed that this is the first reported case of primary biliary cirrhosis presenting with a granulomatous rash.

Clinical and laboratory presentation of lichen planus patients with chronic liver disease

A recent case-control study on 577 lichen planus (LP) patients and 1008 controls confirmed that LP patients may significantly associate with a chronic liver disease (CLD) which is independent from drug or alcohol intake and has some connection with hepatitis B virus (HBV) infection. The study, however, failed to define the nature of CLD. This has been investigated through the clinical and laboratory features of 50 patients with LP and impaired liver function tests. Overall, the laboratory signs of cell necrosis prevailed over those of cholestasis and a good relationship with the HBV and HCV infections was found. Ninety percent of patients with LP and CLD had antibodies to one or another of the major viruses involved in infectious hepatitis. No patient had anti-liver kidney microsomal antibodies type 1. Liver biopsies were done in 12 cases and mostly revealed a chronic active hepatitis evolving into cirrhosis. No evident cases of primary biliary cirrhosis were found. It appears that LP associated CLD is post-viral in nature.

A clinical study of 205 patients with oral lichen planus

Two hundred and five patients with oral lichen planus were divided into two groups: those with only reticular lesions (group 1) and those with atrophic-erosive lesions with or without concomitant reticular lesions (group 2). A comparative study of the two groups showed that the most commonly affected oral location in both was the buccal mucosa. Lesions of the tongue, gingiva, lip, and palate predominated in group 2. Likewise, chronic liver disease and diabetes were more common in the second group, as was extension of the oral lesions (P less than .001).

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.

Lichen planus with simultaneous involvement of the oral cavity and genitalia

Five women with reticular and/or erosive lichen planus of the oral cavity associated with mucous involvement of the genitalia are reported. The presence of a typical lesion in one of these sites requires search for other common sites of involvement as well as manifestations of systemic diseases. Early management and careful follow-up of patients with chronic erosive and atrophic lesions of the vulva should be instituted to prevent dyspareunia. The use of the term plurimucosal lichen planus instead of vulvo-vagino-gingival syndrome is proposed.

Lichen planus and liver diseases: a multicentre case-control study. Gruppo Italiano Studi Epidemiologici in Dermatologia (GISED)

OBJECTIVE

To assess the association of lichen planus with liver complaints and with known aetiological factors of liver diseases.

DESIGN

Multicentre case-control study. Interviews were conducted by trained medical investigators on the basis of a structured questionnaire. At the interview patients and controls were asked for consent to blood samples being taken to determine transaminase activities and the presence of hepatitis B virus surface antigen.

SETTING

Outpatient departments of 27 Italian general and teaching hospitals that were collaborating in the Gruppo Italiano Studi Epidemiologici in Dermatologia (GISED).

SUBJECTS

Incident cases and controls were eligible. A total of 577 patients with lichen planus and 1031 controls with dermatological diseases other than lichen planus were interviewed. Less than 1% of the people contacted refused to participate. Patients and controls were matched for sex and age in five year intervals.

RESULTS

The risk of lichen planus was higher in patients with a history of liver diseases requiring hospital admission or specialist consultation (relative risk = 1.6; 95% confidence interval = 1.2 to 2.2), those who had had liver biopsy (5.5; 1.9 to 15.6), and those with a history of viral hepatitis (1.9; 1.1 to 3.1). High activities of liver enzymes and positive results of tests for hepatitis B virus surface antigen were also associated with lichen planus. The association with alcohol consumption was not clearly confirmed by a dose-risk relation.

CONCLUSION

This study adds quantitative epidemiological evidence to the clinical observation that liver disease is a risk factor for lichen planus although not a specific marker of it.

Isolated lichen planus of the nails associated with primary biliary cirrhosis

Lichen planus is a relatively common inflammatory dermatosis with characteristic lesions affecting the skin, nails and mucous membranes. Nail changes are present in approximately 10% of patients and can occasionally occur in the absence of skin involvement. The association of lichen planus with primary biliary cirrhosis is now well recognized. We report the first case of lichen planus confined to the nails in a patient with primary biliary cirrhosis.

The association of mucocutaneous lichen planus and chronic liver disease

A possible association between mucocutaneous lichen planus and chronic liver disease has been previously postulated in the medical literature. Despite the frequency with which lichen planus occurs in the oral cavity, little mention of such a relationship has been made in the dental literature. A case of lichen planus occurring in a patient with primary biliary cirrhosis and a review of the subject are therefore presented.

Primary biliary cirrhosis

Primary biliary cirrhosis is a chronic liver disease of unknown etiology characterized by slowly progressive intrahepatic cholestasis due to an inflammatory destruction of small intrahepatic bile ducts. The clinical course of PBC is variable ranging from a few years in rapidly progressive cases to a normal life-expectancy in a proportion of asymptomatic cases. The typical patient is a middle-aged woman who may present with pruritus, increasing pigmentation of the skin, and eventually jaundice. The level of serum alkaline phosphatase is almost invariably elevated, serum mitochondrial antibodies are present in more than 90 per cent, and an elevated serum IgM is usually present. PBC is associated with many immunologic abnormalities and appears to be a classic autoimmune disease. Some of the immune defects may be epiphenomena; others such as a marked defect in suppressor T cell function seem to be related to the pathogenesis of the disease. All drug therapy that is aimed at slowing the disease process is experimental. A place for immunosuppressive drugs in the management of PBC would be anticipated. However, no drug has to date been definitively shown to have a beneficial effect on the disease. Currently, the main treatments used are aimed at preventing or correcting the complications of intractable cholestasis. Patients with PBC and evidence of hepatic decompensation and/or poor quality of life make good candidates for liver transplantation. The current aim of therapy is to find an effective regime of immunosuppression that will make hepatic transplantation redundant for this disease.

The autoimmune background in lichen planus

Fifty-four patients with lichen planus (LP) and 54 age- and sex-matched controls were studied. No increase in the incidence of autoimmune disease was found in the patients with LP or their relatives. There was no increase in the frequency of autoantibodies in the LP group and serum immunoglobulin levels were not altered significantly. In the majority of cases, LP is not part of a generalized autoimmune disturbance.

Lichen planus: review and update on pathogenesis

Lichen planus (LP) is a common oral disorder which may represent the manifestation of a mucosal reaction to a variety of aetiological factors. Of the many immunological changes described in LP several may be epiphenomena although a cell-mediated immune response to unidentified antigens or antigenic changes clearly is involved. Associations with drugs or systemic disorders are well-defined in some patients but may, in others, be aleatoric. Finally, the prognosis of oral LP not only differs from that of cutaneous LP but there is little doubt that in a few instances LP is a premalignant condition.

Lichen planus and liver disease: how strong is the association?

One hundred and thirteen patients with histologically confirmed oral lichen planus, from three stomatology clinics, were examined for evidence of liver disease. No patient had clinical evidence of liver disease. Nine patients (7.9%) had a raised serum concentration of a single enzyme; 6 patients had raised gamma-glutamyl transpeptidase, 2 had raised alkaline phosphatase, and 1 had raised aspartate transaminase levels. No patient had serum auto-antibodies suggestive of primary biliary cirrhosis or chronic active hepatitis. Most patients presenting with oral lichen planus are unlikely to have liver disease.