Oral lichen sclerosus—a review of clinical presentation, treatment, and clinical outcomes

Oral and vulval disease: prevalence, associations, and management recommendations for the oral medicine clinician

OBJECTIVE

The oral cavity is a common site for mucosal conditions which may be confined to the mouth, or may manifest as mucocutaneous involvement at other sites, including the anogenital region. This retrospective analysis aimed to assess the appropriateness of oral medicine referrals to a specialized vulval clinic and review the prevalence of oral disease associated with vulval involvement of the same condition.

STUDY DESIGN

One hundred thirty-six patients referred from oral medicine to the vulval service at Guy's Hospital were analyzed. Retrospective data collated included: reason(s) for referral, onset of oral and genital symptoms, oral diagnosis, vulval diagnosis, correlation between the oral and vulval diagnosis, and discharge at first appointment.

RESULTS

Forty-nine percent (n = 67) of the patients had oral and vulval manifestations of the same disease. The majority of these patients (n = 63) were diagnosed with vulval lichen planus, of whom 61 had concomitant oral lichen planus involvement (97%). Other associated oral and vulval diseases included aphthous ulceration, Behçet's disease, dryness secondary to Sjögren's disease, Crohn's disease, and mucous membrane pemphigoid. The remaining 51% (n = 69) of the patients presented with independent vulval conditions unrelated to their oral disease.

CONCLUSION

Clinicians should recognize the association between genital symptoms and oral disease and refer to specialist allied services, as appropriate.

Lack of oral involvement in a large cohort of women with vulvar lichen sclerosus - a multicenter prospective study

BACKGROUND AND OBJECTIVES

We assessed the prevalence of oral lichen sclerosus in a cohort of women affected with vulvar lichen sclerosus (VLS).

PATIENTS AND METHODS

This prospective, observational study included adult female patients with a histologically proven VLS who attended the Vulva Clinics of three Dermatology Units from January 2020 to July 2023. During this period, all VLS patients were asked to be examined in their oral cavities in order to detect any possible sign of oral diseases, which were then biopsied.

RESULTS

Three hundred women (mean age 64.5 ± 13.0 years) were included, of whom 21 (7%) had a concurrent extragenital LS. In six (2%) patients, white, non-removable lesions were found at oral inspection and biopsied. All cases were histologically lichen planus. No other clinically relevant oral lesions were found. The six women with histologically proven oral lichen planus had more frequent periodontal and autoimmune diseases than the other included subjects.

CONCLUSIONS

Our findings confirm the absolute rarity of oral involvement in patients with VLS. They suggest that the oral mucosa, unlike the genitals, is a setting which weakly leads to development of LS, also in predisposed subjects.

Lichen sclerosus: The 2023 update

Lichen sclerosus (LS) is an underdiagnosed inflammatory mucocutaneous condition affecting the anogenital areas. Postmenopausal women are predominantly affected and, to a lesser extent, men, prepubertal children, and adolescents. The etiology of LS is still unknown. Hormonal status, frequent trauma and autoimmune diseases are well-known associations for LS, yet infections do not seem to be clear risk factors. LS pathogenesis involves factors such as a genetic predisposition and an immune-mediated Th1-specific IFNγ-induced phenotype. Furthermore, there is a distinct expression of tissue remodeling associated genes as well as microRNAs. Oxidative stress with lipid and DNA peroxidation provides an enabling microenvironment to autoimmunity and carcinogenesis. Circulating IgG autoantibodies against the extracellular matrix protein 1 and hemidesmosome may contribute to the progression of LS or simply represent an epiphenomenon. The typical clinical picture includes chronic whitish atrophic patches along with itching and soreness in the vulvar, perianal and penile regions. In addition to genital scarring, and sexual and urinary dysfunction, LS may also lead to squamous cell carcinoma. Disseminated extragenital LS and oral LS are also reported. The diagnosis is usually clinical; however, a skin biopsy should be performed in case of an unclear clinical picture, treatment failure or suspicion of a neoplasm. The gold-standard therapy is the long-term application of ultrapotent or potent topical corticosteroids and, alternatively, topical calcineurin inhibitors such as pimecrolimus or tacrolimus. Collectively, LS is a common dermatological disease with a so far incompletely understood pathogenesis and only limited treatment options. To foster translational research in LS, we provide here an update on its clinical features, pathogenesis, diagnosis and (emerging) treatment options.

Oral lesions containing amyloid-like material

During oral pathology daily practice, true amyloid may be identified in oral amyloidosis and several odontogenic tumors. However, histologic examination often reveals other oral and perioral diseases with similar eosinophilic, acellular, amorphous substances. These include extensive areas of collagenous sclerosis, fibrin deposition, elastic fiber degeneration, and dentinoid material, which may resemble amyloid under light microscopic examination. These materials are often termed "amyloid-like" due to their close histologic resemblance to true amyloid. The rarity of most of these conditions and their strong histologic similarity may hamper an accurate diagnosis. Definitive diagnosis of these lesions may require clinical correlation; laboratory evaluation; histochemical or immunohistochemical reactions; and, in some cases, genetic investigation. In this review, we describe the main clinicopathologic features of this group of diseases that may manifest in the oral and/or perioral regions and that have in common the presence of amyloid-like material deposition.

Acquired disorders with depigmentation: A systematic approach to vitiliginoid conditions

Acquired disorders with depigmentation are commonly encountered by dermatologists and present with a wide differential diagnosis. Vitiligo, the most common disorder of acquired depigmentation, is characterized by well-defined depigmented macules and patches. Other conditions, such as chemical leukoderma, can present with similar findings, and are often easily mistaken for vitiligo. Key clinical features can help differentiate between acquired disorders of depigmentation. The first article in this continuing medical education series focuses on conditions with a vitiligo-like phenotype. Early recognition and adequate treatment of these conditions is critical in providing appropriate prognostication and treatment.

Lichen Sclerosus of the Upper Lip: Report of a Case, Utilizing Shikata's Modified Orcein Stain, and Review of the Literature

Background

Lichen sclerosus is a rare chronic inflammatory disorder, affecting mainly the skin and the anogenital mucosa, while oral lesions can be the primary or the only manifestation of the disease. A rare case of oral lichen sclerosus, assessed histopathologically and histochemically, is presented, along with a thorough review of the English language literature.

Methods

A 32-year-old female presented an asymptomatic white patch affecting the skin and the mucosa of the upper lip, without other mucocutaneous involvement. A partial biopsy of the lesion was performed, along with the histochemical Shikata’s modified orcein stain for elastin fibres detection. A literature review was also performed, discussing the epidemiological data, clinical presentation, and treatment modalities of all published cases with oral involvement.

Results

The histopathological evaluation revealed the presence of acellular zone underneath the basal layer of the epithelium, accompanied by deep band-like chronic inflammation. Shikata’s modified orcein stain exhibited scarcity or loss of elastin fibres in the acellular subepithelial area. The diagnosis of lichen sclerosus was made. Topical application of corticosteroids was prescribed and resolution of the lesion was observed. Literature review revealed that oral lichen sclerosus is predominantly presented in females, as asymptomatic lesions of the lips and buccal mucosa; few cases have extraoral manifestations and topical corticosteroids are the main treatment intervention.

Conclusions

Despite its rarity, lichen sclerosus should be considered in the clinical and histopathological differential diagnosis of white patches of the oral mucosa. For rendering proper diagnosis, the histochemical Shikata’s modified orcein stain is a useful assessment tool.