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.

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.

Prevalence of oral lichen planus in diabetes mellitus according to the type of diabetes

OBJECTIVE

The purpose of the present study was to determine the prevalence of oral lichen planus (OLP) in a population of patients with diabetes mellitus (DM) as compared with a control population.

DESIGN

A clinicopathologic study.

SUBJECTS AND METHODS

One hundred and thirty-nine patients with type I DM, 353 patients with type II DM and 274 controls were examined for clinical evidence of OLP. The clinical evidence of OLP in the diabetic and control patients was confirmed by histopathological examination.

RESULTS

The prevalence of OLP in type I diabetic patients was 5.76%, in type II 2.83%, and 1.82% in the controls. The prevalence of OLP was significantly higher in patients with type I DM and slightly higher in patients with type II DM in comparison to the prevalence in the control sample.

CONCLUSIONS

The above findings and the fact that type I diabetes and OLP are characterized by autoimmune phenomena and T cell immune responses respectively, suggest that the immune system may play a critical role in the appearance of OLP in patients with type I DM.

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.

An association between HLA DRI and lichen planus

Serological typing for HLA Class II antigens in 72 patients with lichen planus (LP) revealed a highly significant association with HLA DRI and MTI (DQWI). DRI was present in 80% of patients with generalized LP, 54% with localized LP, 56% of patients with drug-induced LP and in 31% of patients with mucosal LP, compared with 25% of normal controls. MTI (DQWI) was found in 83% of the LP group and 62% of the normal controls. These findings strongly suggest a genetic predisposition or susceptibility to the development of generalized LP and perhaps also to drug-induced LP.

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.

Lichen planus and primary biliary cirrhosis

The association of lichen planus and primary biliary cirrhosis in five patients is reported. The coexistence of the two diseases is probably more than coincidental and may be due to the fact that both conditions are based on an alteration of mechanisms. There is great similarity between primary biliary cirrhosis and chronic graft-versus-host disease and a common pathogenesis for the two entities has been postulated. Since lichen planus is one of the most common manifestations of graft-versus-host disease, its association with primary biliary cirrhosis is of significance, although not unexpected.

Lichen planus with late onset hypogammaglobulinaemia: a casual relationship?

A case of lichen planus of the mouth and vulva associated with late onset hypogammaglobulinaemia, alopecia areata and vitiligo is described, and the possible significance of a B cell defect in the pathogenesis of lichen planus is discussed.

Familial lichen planus. Another disease or a distinct people?

When lichen planus strikes families, a very rare happening, it is likely to afflict younger members, to erupt more acutely, extensively, and gravely, attacking also nails and mucous membranes, and to recur. Ten patients with familial lichen planus, two each from five distinct Caucasian families, the parents of whom were unrelated by birth, were found to be carrying HLA-B7 statistically more frequently than in the normal population or in those with the characteristic forms of lichen planus. We hint that their genotype might have rendered them susceptible to a pathogen that precipitated their disease.

Is there a relationship between lupus erythematosus and lichen planus?

Three patients showing features of both lupus erythematosus and lichen planus are described together with their histological, immunofluorescence and other investigative findings. The similarities between lupus erythematosus and lichen planus are discussed and it is suggested that these may be the result of common pathophysiological pathways.