Lichen planus in two immunodeficient hosts

Oral Lichen Planus in Patients With Good's Syndrome: A Literature Review

Good's syndrome is defined as the association of a thymoma with an immune deficiency. Many patients with Good's syndrome also have oral lichen planus involvement, and some authors have even considered it to be one of the clinical signs of Good's syndrome. In the literature, to our knowledge, clinical forms of oral lichen planus associated with Good's syndrome have not been described. We therefore aimed to characterize the forms of oral lichen planus occurring in the context of Good's syndrome. To this end, we carried out a scoping review of the literature according to the Joanna Briggs Institute guide and included 17 articles on the theme of "the forms and clinical locations of oral lichen planus associated with Good's syndrome". A total of 17 articles were selected, and 19 patients with Good's syndrome including oral lichen planus were identified. Most of them were women aged 60 years with erosive oral lichen planus of the tongue and inner cheeks. The treatments used were thymectomy, to which immunoglobulin infusions were added in some cases. All these treatments resulted in improvement of the oral lichen planus in 70.6% of cases. The management of Good's syndrome allows the improvement of oral lichen. In patients over 50 years of age with acute erosive oral lichen planus refractory to conventional therapies, Good's syndrome should be investigated.

A systematic review of paraneoplastic syndromes associated with thymoma: Treatment modalities, recurrence, and outcomes in resected cases

OBJECTIVE

Paraneoplastic syndromes associated with thymomas remain incompletely understood. The objective was to examine the association between surgically resected thymomas and paraneoplastic syndromes over the past half century.

METHODS

A primary PubMed/MEDLINE search was used to identify published articles describing paraneoplastic syndromes associated with thymomas from 1960 to 2019. A secondary search identified additional articles referenced in the articles found in the primary search. Kaplan-Meier and log-rank test were used for time-to-event data analyses.

RESULTS

From 407 articles describing 507 patients, 123 different paraneoplastic syndromes were associated with thymoma. The 5 most common paraneoplastic syndromes were myasthenia gravis, pure red cell aplasia, lichen planus, Good syndrome, and limbic encephalitis. Complete or partial resolution of paraneoplastic syndrome symptoms after surgery was noted in 76% of patients, of whom 21% had a relapse or new paraneoplastic syndrome onset after surgery. The most common adjunctive therapy associated with resolution of paraneoplastic syndrome was corticosteroids (30%). For all patients after surgery, thymoma recurrence was observed in 17% of cases, whereas recurrence of paraneoplastic syndrome was observed in 34% of cases, and both were observed in approximately 11% of cases. The 5- and 10-year overall survivals were 78% and 66%, respectively. Improved overall survival was associated with patients who had total resolution from paraneoplastic syndrome.

CONCLUSIONS

A comprehensive assessment of publications over the past half century suggests that a multimodal treatment approach that includes surgical resection of thymomas is able to achieve paraneoplastic syndrome resolution in a majority of patients. Onset of new paraneoplastic syndromes after surgery is associated with the recurrence of the first paraneoplastic syndrome, and resolution of paraneoplastic syndrome is associated with improved overall survival.

Lichenoid and interface dermatoses

The terms 'lichenoid' and 'interface' dermatitis are often used interchangeably to describe an inflammatory pattern characterized histologically by damage to the basal keratinocytes in the epidermis. The mechanism of cell damage of such cells is now best understood as apoptosis, or programmed cell death. This inflammatory pattern of dermatoses, is also accompanied frequently by a band of lymphocytes and histiocytes in the superficial dermis, that often obscures the dermal-epidermal junction, hence the term 'lichenoid'. A discussion of the more common lichenoid/interface dermatitides encountered in the routine clinical practice encompasses the following entities: lichen planus, lupus erythematosus, dermatomyositis, erythema multiforme, graft versus host disease, fixed drug reactions, and multiple others.

Lichen planus complicated with thymoma: Report of three Japanese cases and review of the published work

Thymoma is recognized to be complicated with autoimmune diseases, such as myasthenia gravis, pemphigus vulgaris and bullous pemphigoid. Abnormal regulation of autoreactive lymphocytes may be involved in the pathogenesis of the autoimmune diseases. The association of thymoma and lichen planus (LP) is relatively rare. Among 50 patients with LP, we identified three patients with LP accompanied by thymoma (6%; 3/50) in our department from 2004 to 2014. This is the first report identifying the frequency of thymoma accompanied by LP among patients with LP. We herein report three cases of LP accompanied by thymoma along with clinical and histological features. In addition, we summarize 29 LP patients accompanied by thymoma previously reported in the English-language published works. Regarding the complications, hypogammaglobulinemia accompanied 58.6% (17/29) of patients diagnosed with Good's syndrome. Alopecia was present in 13.8% (4/29) of patients, and myasthenia gravis was present in 17.2% (5/29) of patients with LP and thymoma. Among the 27 patients with thymectomy, only 25.9% (7/27) experienced the improvement of LP, suggesting that thymectomy may not be effective for the lesions of LP. Treatment-resistant LP was reported in 54.2% (13/24) of patients. In all our cases, oral lesions were intractable to treatment with oral predonisone and topical steroids and/or tacrolimus. It is important for dermatologists to recognize the clinical characteristics of the patients with both LP and thymoma.

Peripheral T-cell subsets in patients with reticular and atrophic-erosive oral lichen planus

OBJECTIVE

Oral lichen planus (OLP) presents with various clinical forms that can be classified into 2 major types: reticular OLP and atrophic-erosive OLP. Our objective was to investigate immunologic differences between these 2 types.

STUDY DESIGN

We investigated possible immunologic differences between 26 patients with reticular OLP and 26 patients with atrophic-erosive OLP.

RESULTS

No differences were detected in serum Ig levels or complement levels. However, the mean proportions of CD4+CD45RO+ and DR+ lymphocytes were significantly higher in patients with atrophic-erosive OLP than in patients with reticular OLP, whereas the mean proportion of CD8+CD45RA+ lymphocytes was significantly lower in patients with atrophic-erosive OLP.

CONCLUSION

These findings suggest that the 2 clinical types of OLP might have different immunopathogenic mechanisms.

Pemphigus foliaceus and oral lichen planus in a patient with systemic lupus erythematosus and thymoma

A 49-year-old woman with systemic lupus erythematosus, and a history of thymoma and chronic white plaques of the oral mucosa, developed a blistering eruption which was diagnosed as pemphigus foliaceus based on clinical, histological and direct immunofluorescence findings. However, the white plaques had both the clinical and histological features of lichen planus, as well as intercellular antibodies suggestive of pemphigus. Such conditions in combination have been documented previously, but this is believed to be the first report of the coexistence of all four in one individual. The common mechanism underlying these four conditions may well be an immunological disturbance.

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.

Immunologic aspects of dermal and oral lichen planus: a review

There have been many investigations, both experimental and epidemiologic, of the forms of LP affecting the skin and oral mucosae. These studies have provided a varied range of hypotheses to explain not only the factors determining susceptibility to and onset of this disease, but also the immunologic mechanisms leading to the pathosis with which LP is associated. Much progress has been made, especially through in vitro studies, regarding detailed aspects of the immunology of LP. However, data is often conflicting or incomplete. In this review we attempt to bring together the currently available data regarding the immunologic basis of LP.

Hypertrophic lichen planus in three HIV-positive patients: a histologic and immunological study

It is well known that several dermatoses, such as psoriasis vulgaris and seborrheic dermatitis, present with more extensive and severe disease in patients infected with the human immunodeficiency virus (HIV-1). Except for one report, however, lichen planus (LP) has not been described in patients with HIV infection. In this report we describe the clinical and morphological features of 3 HIV-positive patients who presented with extensive hypertrophic LP. To determine if alteration in the immune status in HIV-positive hosts is reflected in the nature of the infiltrate in LP, we determined the proportion of T-helper and T-suppressor cells in the infiltrate in 1 case. The majority of the infiltrating lymphocytes in the dermis were of the T-helper phenotype. Epidermal lymphocytes, however, were predominantly of the T-suppressor phenotype. We conclude that LP in HIV-positive hosts may present with more extensive disease than in immunocompetent hosts. Based on our immunohistochemical studies, we conclude that, similar to immunocompetent hosts, T-helper cells are the predominant cells in the dermal infiltrate of LP in HIV-positive patients. However, in contrast with reports in the literature on LP in immunocompetent hosts, we found that, in the case studied, the epidermal lymphocytes were predominantly of the T-suppressor phenotype.

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.

Cutaneous lymphohistiocytic infiltrates in patients with hypogammaglobulinemia

Six patients (5 to 15 years of age) with hypogammaglobulinemia had scattered papular lesions in association with widespread dermatitis. These disfiguring lesions were a portal of entry for secondary infections and led to social withdrawal. Biopsy specimens from the papules demonstrated dense lymphohistiocytic infiltrate limited to the dermis. Infectious causes (bacterial, fungal, and viral) were excluded. The skin lesions failed to respond to conventional treatment, including topical corticosteroids. Replacement therapy with monthly infusions of high doses of immune serum globulin resulted in gradual improvement and ultimate clearing of the lesions. This unusual skin abnormality, which is unresponsive to traditional treatment, may provide the earliest clue to the presence of hypogammaglobulinemia.

Hypertrophic lichen planus and light sensitivity in an HIV-positive patient

A 40-year-old black man who was HIV positive developed generalized hypertrophic lichen planus in areas previously affected by a photosensitivity eruption. After unsuccessful attempts to induce remission of his lichen planus with conventional therapies, etretinate produced a dramatic response.

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.

Erythroderma with spongiotic dermatitis. Association with common variable hypogammaglobulinemia

Two middle-aged men presented with generalized erythroderma, diffuse alopecia, and hyperkeratosis of the palms and soles. Histopathologic study demonstrated spongiosis (epidermal intercellular edema) with a perivascular lymphohistiocytic infiltrate. Complete immunologic evaluation demonstrated that both patients had panhypogammaglobulinemia and markedly depressed in vitro pokeweed mitogen-induced immunoglobulin secretion. One of the patients also showed poor lymphocyte responses in vitro to T cell mitogens and antigens and had a decreased ratio of helper to suppressor cells. In both patients, the cutaneous lesions improved with systemic corticosteroids, but no significant alteration in the immunologic abnormalities was observed. This report illustrates that chronic erythroderma may be the presenting clinical manifestation of common variable hypogammaglobulinemia.