Sole treatment of lichen planus-associated esophageal stenosis with injection of corticosteroids

Efficacy of a patient with scar constitution combined with corrosive esophageal strictures after different endoscopic therapies

Oral corrosive substances can cause esophageal or gastrointestinal strictures, leading to malnutrition and gastrointestinal dysfunction, directly affecting the patients' quality of life. The aim of the case was to compare the efficacy of different endoscopic therapy methods.

[Esophageal Lichen Planus - An Underdiagnosed Disease]

An involvement of the esophagus in patients with lichen planus was described for the first time in 1982. Ever since, it has been seen as a rarity. However, studies over the last 10 years have shown a higher prevalence than expected. It may even be supposed that esophageal lichen planus (ELP) is more common than eosinophilic esophagitis. ELP mostly affects middleaged women. The principal symptom is dysphagia. Endoscopically, ELP is characterized by denudation and tearing of the mucosa, trachealization and hyperkeratosis and esophageal stenosis may occur in patients with long courses of the disease. Histologic findings including mucosal detachment, T-lymphocytic infiltrate, intraepithelial apoptosis (civatte bodies) and dyskeratosis are crucial. Direct immunofluorescence shows fibrinogen deposits along the basement membrane zone. So far, there is no well-established therapy but a treatment with topic steroids is effective in 2/3 of the patients. Common therapy of lichen planus of the skin seems to be ineffective for treatment of ELP. Symptomatic esophageal stenosis should be endoscopically dilated. ELP joins the group of "new" immunologic diseases of the esophagus.

Der Lichen planus des Ösophagus – Eine unterschätzte Erkrankung

Eine Beteiligung des Ösophagus bei der Hauterkrankung Lichen planus wurde erstmals 1982 beschrieben und fast 30 Jahre lang als eine Rarität angesehen. Untersuchungen der letzten 10 Jahre aber zeigen, dass diese Erkrankung weniger selten ist als angenommen. Es ist sogar anzunehmen, dass der ösophageale Lichen planus (Esophageal Lichen planus, ELP) häufiger ist als die Eosinophile Ösophagitis (EoE). Die Ösophagusbeteiligung betrifft meist Frauen im mittleren Alter. Das Hauptsymptom ist eine Dysphagie. Endoskopisch erkennt man in der Speiseröhre eine charakteristische Schleimhautablösung, eine Trachealisierung, und gelegentlich Hyperkeratosen und bei langem Bestehen auch Stenosen. Wegweisend ist die Histologie mit einer subepithelialen Ablösung sowie einem bandförmigen Infiltrat aus T-Lymphozyten, dem Nachweis von apoptotischen Keratinozyten (Civatte Bodies) und Dyskeratosen. Die direkte Immunfluoreszenz zeigt Fibrinogen-Ablagerungen entlang der Basalmembran. Eine etablierte Therapie gibt es bisher nicht. Die Behandlung mit topischen Steroiden ist in ⅔ der Fälle wirksam. Eine Therapie wie beim klassischen Lichen planus scheint unwirksam zu sein. Bei symptomatischen Stenosen kann eine Dilatation indiziert sein. Der ELP reiht sich in die Gruppe der „neuen“ immunologisch vermittelten Erkrankungen des Ösophagus ein.

Esophageal lichen planus: Current knowledge, challenges and future perspectives

Lichen planus (LP) is a frequent, chronic inflammatory disease involving the skin, mucous membranes and/or skin appendages. Esophageal involvement in lichen planus (ELP) is a clinically important albeit underdiagnosed inflammatory condition. This narrative review aims to give an overview of the current knowledge on ELP, its prevalence, pathogenesis, clinical manifestation, diagnostic criteria, and therapeutic options in order to provide support in clinical management. Studies on ELP were collected using PubMed/Medline. Relevant clinical and therapeutical characteristics from published patient cohorts including our own cohort were extracted and summarized. ELP mainly affects middle-aged women. The principal symptom is dysphagia. However, asymptomatic cases despite progressed macroscopic esophageal lesions may occur. The pathogenesis is unknown, however an immune-mediated mechanism is probable. Endoscopically, ELP is characterized by mucosal denudation and tearing, trachealization, and hyperkeratosis. Scarring esophageal stenosis may occur in chronic courses. Histologic findings include mucosal detachment, T-lymphocytic infiltrations, epithelial apoptosis (Civatte bodies), dyskeratosis, and hyperkeratosis. Direct immuno-fluorescence shows fibrinogen deposits along the basement membrane zone. To date, there is no established therapy. However, treatment with topical steroids induces symptomatic and histologic improvement in two thirds of ELP patients in general. More severe cases may require therapy with immunosuppressors. In symptomatic esophageal stenosis, endoscopic dilation may be necessary. ELP may be regarded as a precancerous condition as transition to squamous cell carcinoma has been documented in literature. ELP is an underdiagnosed yet clinically important differential diagnosis for patients with unclear dysphagia or esophagitis. Timely diagnosis and therapy might prevent potential sequelae such as esophageal stenosis or development of invasive squamous cell carcinoma. Further studies are needed to gain more knowledge about the pathogenesis and treatment options.

[Esophageal Lichen Planus - an Underdiagnosed Disease]

An involvement of the esophagus in patients with lichen planus was described for the first time in 1982. Ever since, it has been seen as a rarity. However, studies over the last 10 years have shown a higher prevalence than expected. It may even be supposed that esophageal lichen planus (ELP) is more common than eosinophilic esophagitis. ELP mostly affects middle-aged women. The principal symptom is dysphagia. Endoscopically, ELP is characterized by denudation and tearing of the mucosa, trachealization and hyperkeratosis and esophageal stenosis may occur in patients with long courses of the disease. Histologic findings including mucosal detachment, T-lymphocytic infiltrate, intraepithelial apoptosis (civatte bodies) and dyskeratosis are crucial. Direct immunofluorescence shows fibrinogen deposits along the basement membrane zone. So far, there is no well-established therapy but a treatment with topic steroids is effective in 2/3 of the patients. Common therapy of lichen planus of the skin seems to be ineffective for treatment of ELP. Symptomatic esophageal stenosis should be endoscopically dilated. ELP joins the group of "new" immunologic diseases of the esophagus.

Esophageal lichen planus: towards diagnosis of an underdiagnosed disease

Background: Although lichen planus (LP) is a common skin disorder, the prevalence of esophageal involvement (ELP) and its clinical manifestations are poorly defined. We aimed to establish diagnostic criteria and characterize disease outcomes of ELP.Methods: Clinical, endoscopic, histological, and immunofluorescence data from consecutive patients with known LP between 2013 and 2018 were analyzed. We established endoscopic (denudation and tearing of the mucosa, hyperkeratosis and trachealization) and histological criteria (mucosal detachment, T-lymphocytic infiltrate, intraepithelial apoptosis, dyskeratosis, and fibrinogen deposits along the basement membrane) to grade disease severity. Endoscopic findings were correlated with clinical symptoms. Response to medical therapy was monitored.Results: Fifty-two consecutive patients (median age 59.5 years) were analyzed. According to our grading system, 16 patients were considered as severe and 18 as mild ELP. Dysphagia was the only symptom which differentiated patients with severe (14/16) or mild ELP (8/18) from patients without ELP (1/18). Concomitant oral and genital involvement of LP was associated with the presence of ELP, while oral involvement alone was not. Follow-up of 14/16 patients with severe EPL for at least one year revealed that most of these patients responded to topical corticosteroids (budesonide: n = 9/10 or fluticasone n = 2/2). Three budesonide patients experienced a resolution of symptomatic esophageal stenosis.Conclusions: Esophageal involvement of LP is frequent, but may be asymptomatic. ELP can be diagnosed using the diagnostic criteria proposed here. Dysphagia and combined oral and genital manifestation are associated with ELP. Therapy with topical corticosteroids appears to be a prudent therapeutic approach for ELP.

Oesophageal lichen planus: the efficacy of topical steroid-based therapies

BACKGROUND

Oesophageal lichen planus is an idiopathic inflammatory disorder characterized by significant oesophageal stricturing. Oesophageal lichen planus is a rare, difficult to diagnose, and likely an under recognized disease. As a result, there is no standardized approach to therapy and treatment strategies vary.

AIM

To examine the utility of topical steroid therapy (fluticasone or budesonide) in the management of oesophageal lichen planus.

METHODS

A retrospective chart review was conducted of patients diagnosed with oesophageal lichen planus who underwent baseline and follow up endoscopy pre and post topical steroid therapy between 1995 and 2016 at Mayo Clinic, Rochester MN. Average time between upper GI endoscopy was 3.2 months (0.7-11.7). Swallowed steroid preparations included fluticasone 880 μg twice daily or budesonide 3 mg twice daily. Patients were reviewed for symptomatic response to therapy using the Dakkak-Bennett dysphagia score (0-4, no dysphagia to total aphagia). Pre- and post-endoscopic findings were assessed. Additional baseline demographic, endoscopic, and histologic data were also obtained.

RESULTS

We identified 40 patients who met the inclusion criteria. A significant reduction in median dysphagia score from 1 (0-4) to 0 (0-3) after steroid therapy (P < 0.001) was noted. 62% of patients reported resolution of their dysphagia after receiving topical corticosteroids. 72.5% had an endoscopic response to steroid therapy.

CONCLUSION

Topical swallowed budesonide or fluticasone appear to effective treatment for oesophageal lichen planus.

Esophageal involvement is frequent in lichen planus: study in 32 patients with suggestion of clinicopathologic diagnostic criteria and therapeutic implications

OBJECTIVE

Lichen planus (LP) is a classic skin disease that can involve the skin, hair, and nails, as well as the oral and genital mucosa. Histopathology is characterized by a T-lymphocytic, lichenoid, and interface dermatitis. Multiple case reports and small case series have shown that LP can involve the esophagus. However, the diagnostic criteria, incidence, and best treatment options remain uncertain. This study aimed to refine the diagnostic criteria, estimate prevalence, and present an outlook on treatment options to prevent long-term sequelae.

PATIENTS AND METHODS

Thirty-two consecutive patients with LP of the skin, hair, nails, oral mucosa, and/or genital mucosa underwent a comprehensive clinicopathologic assessment. Esophagogastroduodenoscopy was performed, and biopsies were evaluated histologically, immunohistochemically, and by direct immunofluorescence. Patients diagnosed with esophageal lichen planus (ELP) were followed up prospectively where possible.

RESULTS

In total, 20 of 32 patients had ELP. Ten of these 20 patients were classified as having proven ELP, with clear-cut endoscopically visible lesions; the other 10 were classified as having probable ELP. Eight of 10 patients with proven ELP were started on new or additional therapy because of esophageal findings. Treatment with a topical budesonide formulation or systemic corticosteroids was successful in most patients with proven ELP and reversed functional esophageal stenosis.

CONCLUSION

ELP can be found in more than 50% of patients with proven mucocutaneous LP when clinical and pathologic findings are correlated carefully. Topical or systemic corticosteroids are the first-line therapy for ELP. Timely medical therapy seems to prevent scarring stenosis of the esophagus.

Successful Treatment of a Persistent Esophageal Lichen Planus Stricture With a Fully Covered Metal Stent

We report a case of a 51-year-old woman with an esophageal lichen planus (ELP) stricture refractory to medical therapy and endoscopic stricture dilation. A multidisciplinary decision was made to place an esophageal fully covered metal stent. The stent was removed 6 weeks later and the patient is doing well on 3-month follow up. We show that a removable esophageal stent is an option after standard medical therapy and endoscopic dilations fail. This is the first reported use of an esophageal stent for therapy of an ELP stricture.

Management of symptomatic esophageal involvement with lichen planus

AIM

To describe the clinical features and treatment schedules of a series of 5 patients with esophageal lichen planus (LP). To review the literature on esophageal LP.

BACKGROUND

LP, a common papulosquamous dermatologic condition, can present to the gastroenterologist with esophageal involvement. This is rare and occurs in a distinct population of LP patients. Disease at this site is frequently refractory to conventional treatment.

CASE SERIES

Between 2001 to 2007, 5 female patients were diagnosed with esophageal LP. They all had esophageal strictures which were treated with a combination of balloon dilatation and intralesional triamcinolone. Therapeutic intervention was covered with oral steroids before and after the procedure. Symptoms tended to recur, necessitating repeat procedures. The average interval between treatments was 8.3 months.

CONCLUSIONS

Intralesional triamcinolone and balloon dilatation produced good symptomatic relief in these 5 patients with esophageal LP. This was generally maintained for several months. We reviewed 35 cases of symptomatic esophageal LP in the English literature. Esophageal LP seems to have a striking predilection for middle-aged women, particularly those with disease at other mucosal sites. A range of systemic immunosuppressants and esophageal-directed therapies has been tried.

Esophageal lichen planus: case report and literature review

Lichen planus is an inflammatory mucocutaneous disorder that typically affects the flexor skin surfaces, mucous membranes, and genitalia. We describe a case of severe esophageal lichen planus associated with typical mucocutaneous manifestations and discuss the presentation, diagnosis, and difficulties encountered in treatment. The published literature is reviewed and treatment strategies described.