Hepatitis C virus (HCV)-infection and oral lichen planus

Bidirectional Association between Lichen Planus and Hepatitis C-An Update Systematic Review and Meta-Analysis

Lichen planus (LP) is a chronic, inflammatory mucocutaneous disorder associated with systemic diseases such as hepatitis C (HCV). The objective of this study is to evaluate the association between LP and HCV bidirectionally through a systematic review and meta-analysis. A comprehensive search of studies published was performed in the databases of PubMed, Embase, and Web of Science. Out of 18,491 articles, 192 studies were included. The global prevalence of HCV positive (HCV+) in LP patients registered from 143 studies was 9.42% [95% confidence interval (CI), 7.27-11.58%], and from these, 84 studies showed HCV+ 4-fold more frequent in LP than a control group (OR, 4.48; 95% CI, 3.48-5.77). The global prevalence of LP in patients HCV+ recorded from 49 studies was 7.05% (95% CI, 4.85-9.26%), and from these, 15 registered a 3-fold more LP in HCV (OR, 3.65; 95% CI, 2.14-6.24). HCV+ in LP patients showed great geographic variability (OR, 2.7 to 8.57), and the predominantly cutaneous location was higher (OR, 5.95) than the oral location (OR, 3.49). LP in HCV+ patients was more frequent in the Eastern Mediterranean (OR, 5.51; 95% CI, 1.40-15.57). There is a higher prevalence of HCV+ in LP and vice versa than in the control group, especially in certain geographical areas that should be taken into consideration when doing screening in countries with an upper prevalence of HCV among the general population.

Are oral lichen planus patients at high risk of hepatitis C? A case-control study

OBJECTIVE

To assess the correlation between oral lichen planus (OLP) and viral hepatitis C (HCV).

METHODS

This retrospective case-control study included a sample of OLP patients in a 3-year interval. The predictor variable was the presence of OLP (yes/no). The outcome variable was the diagnosis of HCV. Other study variables were grouped into demographic, anatomic, and clinical. Descriptive, bi- and multivariate statistics were computed with a significant level at P ≤ 0.05.

RESULTS

The sample was composed of 237 OLP patients (38.8% females) with a mean age of 59.9 ± 17.8 years (range, 17-96), and 948 age- and gender-matched control individuals. The significant higher frequency of HCV was identified in OLP patients (frequency: 19.8% vs. 2.1%; adjusted matched odds ratio [mOR_adj], 9.5; 95% confidence interval [95% CI], 5.98 to 15.91; P < 0.0001; Pearson's Phi coefficient [r_phi], 0.307). In the adjusted model, OLP with HCV was associated with 1) oro-cutaneous manifestations (mOR_adj, 17.58; 95% CI, 1.92 to 161.26; P = 0.0059; Bayesian posterior probability of positive test [W_p], 96%), 2) any intraoral forms other than reticular/plaque-liked forms (mOR_adj, 0.09; 95% CI, 0.04 to 0.18; P < 0.0001; W_p, 52%), and 3) poor response to topical corticosteroids (mOR_adj, 0.05; 95% CI, 0.02 to 0.16; P < 0.0001; W_p, 88%).

CONCLUSIONS

OLP, especially oro-cutaneous disease or steroid-refractory OLP, are associated with an increased frequency of HCV. Not only HCV screening in OLP patients, but oral examination in HCV patients, are both recommended as primary preventive measures.

No association of oral lichen planus and hepatitis C virus infection in central Germany

OBJECTIVES

Co-occurrence of oral lichen planus (OLP) and chronic hepatitis C virus (HCV) infection suggests a strong association, but the relation between mucocutaneus, autoimmune lichen planus and HCV infection remains unclear. In areas with higher prevalence of HCV infection in general population, like Japan and southern Europe, 20 to 40 % of patients with OLP test positive for anti-HCV antibodies, whereas in German populations, a co-occurrence of 4.2 to 16 % was reported.

MATERIAL AND METHODS

We screened 143 patients with histopathologically proven OLP for prevalence of anti-HCV antibodies. Additionally, we examined 51 anti-HCV-positive subjects with current or past HCV infection for clinical symptoms of OLP. In all patients, confirmatory diagnosis was made by the detection of HCV RNA via reverse transcription-polymerase chain reaction (RT-PCR). A randomized control group comprised 109 blood sera samples of patients without any characteristics of OLP.

RESULTS

The results of all patients showed no co-occurrence in either cohort.

CONCLUSION

In conclusion, no association between oral lichen planus and chronic HCV infection in our study population was found.

CLINICAL RELEVANCE

Anti-HCV antibody screening in patients with confirmed oral lichen planus is not indicated routinely in central Germany.

Dermatologic Extrahepatic Manifestations of Hepatitis C

Hepatitis C virus (HCV) affects millions of people worldwide, and an estimated 3.2 million people in the United States. HCV is a hepatotropic and lymphotropic virus that causes not only liver disease, but also a significant number of extrahepatic manifestations (EHMs). Up to 74% of patients affected by HCV will have HCV-related EHMs of some severity in their lifetime. The EHMs vary from simple cutaneous palpable purpura to complex lymphoproliferative disorders, including lymphomas and immune-complex deposit diseases causing local and/or systemic complications. Mixed cryoglobulinemia (MC) is manifested by multiple systemic organ involvement, mainly skin, kidney, peripheral nerves, and salivary glands, and less frequently causes widespread vasculitis and malignant lymphoma. MC affects up to 3% of HCV-infected patients with cryoglobulinemia of clinical significance, i.e. >6%. Severe disease requires immunosuppressive or plasma exchange therapy. HCV prevalence in the United States in patients with porphyria cutanea tarda (PCT) was reported to be 66%, much higher than that in general population. Therefore, all patients with PCT should be screened for HCV. The skin rash of PCT varies from large blisters to small vesicles and/or milia on the hands. Skin manifestations due to PCT usually respond to anti-HCV treatment together with reducing skin sun exposure, avoiding triggers, having routine phlebotomy (especially for people with chronic iron overload states), and using chloroquine. Lichen planus (LP), which typically affects both the skin and oral mucosa is a chronic inflammatory disease of squamous cell origin affecting about 1% of the worldwide population. The prevalence of HCV in patients with LP varies based on geographic location. We review here the basic pathophysiology, clinical features, and management of dermatologic manifestations of HCV.

Hepatitis C virus infection and lichen planus: a systematic review with meta-analysis

OBJECTIVE

Hepatitis C virus (HCV) is one of the major causes of chronic liver disease worldwide but its morbidity is also due to a variety of extra-hepatic manifestations including mixed cryoglubulinemia, non-Hodgkin lymphoma, diabetes, porphyria cutanea tarda and lichen planus. The aims of this study were to conduct a systematic review and a meta-analysis on the prevalence of HCV in lichen planus patients and on the prevalence of lichen planus in chronic HCV infection.

MATERIALS AND METHOD

Bibliographic searches were conducted in several electronic databases. Pooled data were analysed by calculating odds ratios, using a random effects model.

RESULTS AND CONCLUSIONS

Thirty-three studies comparing the seroprevalence of HCV in lichen planus patients and six reporting the prevalence of lichen planus in patients with HCV infection were included in the meta-analysis. The summary estimate showed that LP patients have significantly higher risk (odds ratio 4.85; 95% confidence interval 3.58-6.56) than controls of being HCV seropositive. A similar odds ratio of having lichen planus was found among HCV patients (4.47; 95% confidence interval 1.84-10.86). Sub-analyses indicated that variability of HCV/lichen planus association seemed only partially depending on geographic effect.

Pathophysiology, etiologic factors, and clinical management of oral lichen planus, part I: facts and controversies

Lichen planus (LP) is an inflammatory disease of the stratified squamous epithelia of unknown etiology. LP affects most frequently the oral mucosa, but it may also involve other mucosa and the skin. Oral LP (OLP) most frequently affects woman aged between 30 and 60 years. Histopathologic examination typically shows orthokeratotic hyperkeratosis, basal cell degeneration, and a dense well-defined infiltrate of lymphocytes in the superficial dermis. OLP lesions may result from the induction of keratinocytes apoptosis by cytotoxic CD8+ T cells stimulated by a yet unidentified self-antigen on a genetically predisposed patient. The association of OLP with hepatitis C virus (HCV) has been more consistently demonstrated in the Mediterranean area. Although HCV RNA and HCV-specific CD4+ and CD8+ T cells have been retrieved in the mucosal lesions of patients with chronic HCV infection and OLP, the eventual pathophysiology of HCV in OLP lesions remains unclear. Available treatments of OLP are not curative, and many have potentially prominent side effects. The objectives of OLP management should be to prevent and screen for malignant transformation and alleviate symptoms on the long-term. Avoidance of potential precipitating drugs, tobacco, alcohol, and local trauma, as well as strict oral hygiene, is essential. The first-line pharmacologic treatment relies on topical steroids. Systemic steroids should be limited to the short-term cure of severe refractory OLP. Life-long clinical follow-up, at least annually, is fundamental.

Evaluation of Relationship between Lichen Planus and HCV Antibody

BACKGROUND AND AIMS

Lichen planus is a relatively common chronic mucocutaneaous disease with an unknown cause, and is considered a manifestation of cell-mediated immune response. Hepatitis C virus (HCV) and its subgroups have been associated with lichen planus in different geographic locations. The present study was undertaken to evaluate the prevalence of HCV antibody in patients with lichen planus in northwest Iran.

MATERIALS AND METHODS

This descriptive analytical study included 30 patients with cutaneous lichen planus, 30 pa-tients with oral lichen planus, and 30 healthy individuals as controls. Anti-HCV test was run for all the subjects. Descriptive statistics as well as chi-square test, to compare means in the three study groups, were applied to the data using SPSS 14.0 computer software.

RESULTS

Age and sex differences between the groups were not significant. No statistically significant differences were ob-served in anti-HCV test results between the groups (P = 0.50).

CONCLUSION

No statistically significant relationships were observed between lichen planus and HCV antibody in the studied samples.

Extrahepatic manifestations of hepatitis C virus infection

Hepatitis C virus may cause hepatic and extrahepatic diseases. Extrahepatic manifestations range from disorders for which a significant association with viral infection is supported by epidemiologic and pathogenetic data, to anecdotal observations without clear proof of causality. This article describes the diagnosis and treatment of these diseases.

Oral diseases associated with hepatitis C virus infection. Part 2: lichen planus and other diseases

Some of the most frequent extrahepatic manifestations of hepatitis C virus (HCV) infection involve the oral region predominantly or exclusively. Part 2 of this review discusses the current evidences regarding the association of lichen planus (LP) and other diseases frequently involving the oral cavity with HCV. Epidemiological data suggest that LP may be significantly associated with HCV infections especially in southern Europe and Japan but not in northern Europe. These geographical differences are possibly influenced by immunogenetic factors, the duration of the HCV infection and the design of the published studies. Because of the fact that most of the studies published are retrospective, it is impossible to establish whether the HCV exposure occurred earlier to or after the onset of disease and more prospective studies are clearly warranted. As the virus may replicate in the skin and oral mucosa and HCV-specific T lymphocytes can be found in the oral mucosa of patients with chronic hepatitis C and LP, HCV may be implicated in the pathogenesis of LP. However, little attention has been paid to the variable effect of therapy with interferon-alpha (IFN-alpha), with or without ribavirin for LP. Conversely, it is unlikely that other oral diseases such as oral carcinoma, pemphigus and Behcet disease are triggered by HCV.

Extrahepatic manifestations of Hepatitis C Virus infection: a general overview and guidelines for a clinical approach

Hepatitis C Virus is associated with a wide series of extrahepatic manifestations. Based on available data the link between the virus and some of these extrahepatic diseases is only suggested and needs further confirmation. Hepatitis C Virus-related lymphoproliferative disorders, whose prototype is mixed cryoglobulinaemia, represent the most closely related extrahepatic manifestations of Hepatitis C Virus. Other Hepatitis C Virus-associated disorders include nephropathies, thyreopathies, sicca syndrome, idiopathic pulmonary fibrosis, porphyria cutanea tarda, lichen planus, diabetes, chronic polyarthritis, cardiopathy and atherosclerosis. A pathogenetic link between Hepatitis C Virus and some extrahepatic manifestations was confirmed by their responsiveness to antiviral therapy, which is now deemed the first therapeutic option to consider. By contrast, there are diseases where treatment with interferon was ineffective or dangerous. The aim of the present paper is to outline the most recent evidence concerning extrahepatic disorders that are possibly associated with Hepatitis C Virus infection. Special emphasis will be given to discussion of the most appropriate clinical approaches to be adopted in order to diagnose, treat (possibly prevent) and follow-up extrahepathic diseases in patients with Hepatitis C Virus infection.

Associação entre líquen plano e infecção pelo vírus da hepatite C: um estudo prospectivo envolvendo 66 pacientes da clínica de dermatologia da Santa Casa de Misericórdia de São Paulo

FUNDAMENTOS: O líquen plano é dermatose inflamatória crônica de etiologia desconhecida. Sua associação com doença hepática, particularmente a hepatite C, é tema de diversos trabalhos em todo o mundo, desde 1990, quando a sorologia para detecção do vírus da hepatite C (VHC) se tornou disponível. OBJETIVOS: Este estudo visa avaliar uma possível relação causal entre a infecção pelo vírus C e o líquen plano. MÉTODOS: Tomaram-se por grupo de estudo 66 pacientes com líquen plano matriculados na Clínica de Dermatologia da Santa Casa de Misericórdia de São Paulo, no período de 2000 a 2003. O grupo comparativo foi constituído pelos doadores de sangue voluntários do Banco de Sangue da Santa Casa de Misericórdia de São Paulo, durante o período de outubro de 2001 a outubro de 2002. RESULTADOS: Dos 66 pacientes com líquen plano, cinco apresentaram sorologia positiva para VHC, representando 7,5% em comparação com 0,69% dos doadores de sangue. CONCLUSÕES: Esse resultado é compatível com muitos dados contidos na literatura médica mundial. Entretanto, são necessários novos estudos para o melhor conhecimento dessa controversa relação.

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.

Mucosal vulval lichen planus: outcome, clinical and laboratory features

BACKGROUND

Mucosal lichen planus of the vulva is a rare but increasingly recognized condition. It has potentially severe complications such as fusion of the labia and vagina; the risk of developing squamous cell carcinoma (SCC) may be increased. An association between hepatitis B and C infection and skin or oral lichen planus appears to exist in certain geographical areas.

OBJECTIVE

To investigate the course of mucosal vulval lichen planus, its response to treatment and associated laboratory features.

SUBJECTS AND METHODS

Forty-four women with mucosal vulval lichen planus were studied between 1997 and 2000 and laboratory data were collected.

RESULTS

Thirty of 44 patients had additional oral lesions, only nine had cutaneous findings compatible with lichen planus. We did not find an association with antibodies to hepatitis B or C virus in this British study population. All women were treated with potent to very potent topical corticosteroids; however, in the majority of patients symptoms persisted. In seven (16%) patients vulval lichen planus was in remission after a disease duration between 2 and 18 years (mean 10.6 years). One patient developed a vulval SCC.

CONCLUSIONS

Screening for hepatitis B and C in women with mucosal vulval lichen planus in the UK seems unnecessary. We recommend long-term follow-up, and that all non-healing ulcerative and papular lesions should be biopsied.

Hepatitis C virus and lichen planus

Hepatitis C virus (HCV) is an important factor in the development of chronic liver disease and hepatocellular carcinoma. In recent years it has become known that HCV induces various extrahepatic manifestations including mixed cryoglobulinemia, membranoproliferative glomerulonephritis, Sjögren's syndrome, autoimmune thyroiditis, malignant lymphoma, porphyria cutanea tarda and lichen planus. Although the mechanisms of extrahepatic manifestations remain unclear, it is known that interferon (IFN) therapy and coadministration of IFN with ribavirin are effective in promoting the disappearance or alleviation of such extrahepatic lesions, which have tended to be overlooked. The present review focuses on lichen planus, one of the major extrahepatic manifestations.

Lack of evidence of hepatic disease in patients with oral lichen planus in Serbia

OBJECTIVE

The reported frequency of chronic liver disease, and particularly, Hepatitis C virus (HCV) infection in patients with oral lichen planus (OLP) shows geographical variation. The aim of this study was to determine the prevalence of chronic hepatic disease, Hepatitis B virus and HCV infection in patients with OLP and control subjects resident in Serbia.

PATIENTS AND METHODS

In this prospective study 48 patients with OLP (33 women and 15 men, with a mean age of 49.7 years) and 60 control subjects (38 women and 22 men, with a mean age of 46.7 years) were examined for the presence of serological evidence of chronic hepatic disease, Hepatitis B surface antigen (HBsAg) and anti-HCV seropositivity.

RESULTS

All patients with OLP had normal liver function. HBsAg was not found in any of the patients with OLP or control group. None of the patients with OLP or control subjects were HCV seropositive.

CONCLUSION

Patients with OLP resident in Serbia do not have evidence of chronic liver disease or infection with HBV or HCV. The exact aetiological role between hepatic disease and OLP remains unclear.

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.

Molecular evidence that the hepatitis C virus replicates in the oral mucosa

BACKGROUND/AIMS

Patients infected with the hepatitis C virus (HCV) often have extrahepatic manifestations, which significantly contribute to HCV-related morbidity, but whose pathogenesis is largely unknown. Our aim was to evaluate the HCV replication in oral mucosa of chronic hepatitis C patients.

METHODS

We collected oral mucosa specimens from 17 anti-HCV-positive and four anti-HCV-negative patients. Fifteen had oral lichen (12 anti-HCV-positive). Total mucosa RNA was extracted and analyzed for presence and titer of genomic and negative-strand HCV RNA. Findings were compared with clinical and pathological features.

RESULTS

Genomic and negative-strand HCV RNA were detected, respectively, in 12 of 17 (70.6%) and four of 17 (23.5%) specimens from the chronic hepatitis C patients. No negative-strand HCV RNA was detected in five anti-HCV-positive patients without lichen (including three with normal mucosa). Presence and titer of the negative-strand HCV RNA were independent of HCV genotype, serum viral load, and histological diagnosis of liver lesions. The phylogenetic analysis of the envelope 2 region cloned from a normal mucosa and the corresponding serum further suggested that only lichen tissues appear to harbor replicating HCV.

CONCLUSIONS

HCV may occasionally replicate in oral lichen tissue, possibly contributing to the pathogenesis of mucosa damage.

Extrahepatic manifestations of infection with hepatitis C virus

Chronic hepatitis C is associated with, and may trigger or exacerbate, an extraordinary variety of extrahepatic manifestations. Most of these manifestations affect the skin, the most frequent and important of which are the leukocytoclastic vasculitis of MC type II and PCT. The former is an example of an autoimmune disorder triggered by HCV infection, whereas PCT is a skin disease caused by hepatic overproduction of uro- and 7-carboxyl porphyrins caused by increased oxidative stress in hepatocytes. Currently available effective therapies of CHC (IFN, ribavirin) may also trigger or exacerbate extrahepatic manifestations, especially including autoimmune thyroiditis, skin rashes, and hemolytic anemia.

Hepatitis C: a review and update

The hepatitis C virus is an RNA virus that is a major cause of acute and chronic hepatitis. It is contracted chiefly through parenteral exposure to infected material such as blood transfusions or injections with dirty needles. Those at highest risk for development of hepatitis C are injection-drug users, people who snort cocaine with shared straws, and health care workers who are at risk for needle-stick and other exposures. Although the incidence of acute hepatitis C infection has fallen dramatically in the United States during the past decade, the prevalence of infection remains high (approximately 2.7 million Americans) because chronic hepatitis C develops in about 75% of those infected. Both acute and chronic hepatitis C are asymptomatic in most patients. However, chronic hepatitis C is a slowly progressive disease and results in severe morbidity in 20% to 30% of infected persons. Chronic hepatitis C is associated with a host of extrahepatic manifestations, many of which may be seen by dermatologists. The most frequent of these are mixed cryoglobulinemia with leukocytoclastic vasculitis and porphyria cutanea tarda. (J Am Acad Dermatol 2001;44:159-79.)

LEARNING OBJECTIVE

At the conclusion of this learning activity, participants should be familiar with the essentials of the virology of the hepatitis C virus and the major features of the human diseases caused by hepatitis C viral infection; the extrahepatic manifestations of hepatitis C viral infection, with particular emphasis upon dermatologic manifestations, including leukocytoclastic vasculitis, porphyria cutanea tarda, and lichen planus; and the current methods of management of hepatitis C and its extrahepatic manifestations.