Diagnosis and management of oral lichen planus

Oral lichen planus and associated comorbidities: An approach to holistic health

Lichen planus (LP) is a chronic inflammatory disorder with involvement of skin, oral and genital mucosa, scalp, and nail appendages. Oral lichen planus (OLP) lesions demonstrate a number of morphologic presentations, persist for a long time with rare self-resolution, and undergo malignant changes. OLP has been associated with numerous systemic connotations such as metabolic syndrome, diabetes mellitus, hypertension, thyroid diseases, psychosomatic ailments, chronic liver disease, gastrointestinal diseases, and genetic susceptibility to cancer. The oral health physician should be aware of these systemic associations and should work in close connect with the primary healthcare physicians to rule out the predisposing factors for the associated comorbidities. This article aims to highlight the various systemic associations of OLP and warrants the screening of these ailments in OLP for prevention and effective management.

Pimecrolimus 1% cream for oral erosive lichen planus: a 6-week randomized, double-blind, vehicle-controlled study with a 6-week open-label extension to assess efficacy and safety

OBJECTIVE

To assess the efficacy and safety of topical pimecrolimus 1% cream in the treatment of oral erosive lichen planus.

DESIGN

A 6-week randomized, double-blind, vehicle-controlled phase followed by a 6-week open-label phase.

SETTING

Outpatients of the Department of Dermatology, University of Utah.

PATIENTS

Twenty-one patients with oral erosive lichen planus were randomized and treated with either pimecrolimus 1% cream or vehicle cream.

INTERVENTION

Pimecrolimus 1% cream, or its vehicle, were applied twice daily for 6 weeks to each side of the mouth with a 2×2 inch gauze pad folded in half and placed directly on the erosive lesion.

MAIN OUTCOME MEASURES

Efficacy was based on clinical evaluation of Investigator's Global Assessment (IGA) of the overall severity of the disease, erythema, measurement of the size of any target erosion in millimetres, and assessment of spontaneous pain. Blood levels of pimecrolimus were monitored in all subjects on day 0 and repeated on day 7.

RESULTS

Pimecrolimus 1% cream was superior to vehicle cream in reducing mean IGA, pain, and erosion size. For the vehicle group that entered the open-label phase, pimecrolimus 1% cream improved the mean IGA, pain, erosion size, and erythema. Pimecrolimus levels were detected in nine out of 10 of the pimecrolimus-treated subjects. These levels were consistently low. The pimecrolimus cream was well-tolerated. No clinically relevant, drug-related adverse events were reported.

CONCLUSION

Pimecrolimus 1% cream was superior to vehicle in reducing pain, erythema, decreasing erosion size, and improving overall severity of disease when compared with vehicle treatment.

Oral lichen planus: clinical features, etiology, treatment and management; a review of literature

Lichen planus is a chronic inflammatory mucocutaneous disease. Mucosal lesions are classified into six clinical forms and there is malignant potential for two forms of OLP; therefore, follow-up should be considered. There are many un-established etiological factors for OLP and some different treatment modalities are based on etiology. The aims of current OLP therapy are to eliminate mucosal erythema and ulceration, alleviate symptoms and reduce the risk of oral cancer. We have used review papers, case reports, cohort studies, and case-and-control studies published from 1985 to 2010 to prepare this review of literature.

Results of patch testing in patients diagnosed with oral lichen planus

BACKGROUND

Oral lichenoid lesions (OLLs) resemble oral lichen planus (OLP) but develop secondary to various underlying causes. The role of contact allergy in precipitating and/or perpetuating OLL is well documented but remains controversial.

OBJECTIVE

To help elucidate the association of contact allergy and OLL, we reviewed patch-test readings in patients diagnosed with OLP-like lesions.

METHODS

We retrospectively reviewed patients diagnosed with OLP-like lesions who had patch tests performed between January 1, 2006, and December 31, 2007.

RESULTS

Patch tests were performed on 24 patients with a histopathologic and/or clinical diagnosis of OLP. Of these, 16 (67%) had positive patch-test readings. At least eight (50%) of these patients had clinically relevant reactions. Ten of the 16 patients (63%) had reactions to metals. In most of these patients, troublesome areas tended to localize adjacent to metallic dental restorations. Of the nine patients (56%) who had reactions to fragrances, flavorings, gallates, and/or diallyl disulfide, the majority improved after avoiding these allergens.

CONCLUSION

Our findings support the notion that contact allergy may underlie the pathogenesis of OLL and that allergen avoidance may result in amelioration of disease.

Oral lichen planus in childhood

Oral lichen planus is rare in childhood, and only a few reports on this subject have appeared in the literature. Our objective was to report individual cases of oral lichen planus in childhood from our practice and to review the literature on this subject. We recruited patients younger than 18 years with oral lichen planus and documented several clinical aspects, the histopathology, patch tests, and blood examination findings. Three patients from about 10,000 dermatology patients younger than 18 years seen from 1994 to 2003 were included. Of these three, an Asian girl aged 11 years had an asymptomatic, hyperkeratotic variant of oral lichen planus, which disappeared without any treatment after 1 year. An Asian boy aged 16 years had an erosive oral lichen planus with severe pain, which healed after intensive local and systemic treatment in 2 years. A Caucasian girl aged 14 years had a hyperkeratotic variant with a little soreness, which disappeared with local treatment after 3 months. Our findings indicated that oral lichen planus in childhood is rare and therefore at present it is not possible to draw firm conclusions considering its nature and etiology. Oral lichen planus in childhood seems to occur preferentially in those of Asian race. The clinical features resemble those of oral lichen planus in adults. However, generally the prognosis of oral lichen planus in childhood seems to be more favorable than in adults.

Oral lichen planus part II: therapy and malignant transformation

Oral lichen planus lesions can cause discomfort, pain, and a burning sensation. Therefore, all professionals who deal with the oral cavity must be aware of all the therapeutic options for it. This article presents a review of the literature on oral lichen planus, focusing on its treatment, and also discusses the important and controversial potential for the evolution of oral lichen planus into epidermoid carcinoma.

Lichen planus esophagitis: report of three patients treated with oral tacrolimus or intraesophageal corticosteroid injections or both

Clinically significant involvement of the esophagus is uncommon in patients who have lichen planus, a common disorder of squamous epithelium. In three patients who had oral, cutaneous, and esophageal lichen planus, endoscopic intralesional esophageal injection of corticosteroids (in all three patients) and oral tacrolimus (FH506) (in two patients) resulted in improvement in dysphagia, a less frequent need for dilation, and improvement in esophageal inflammation.

Topical tacrolimus in the treatment of symptomatic oral lichen planus: a series of 13 patients

BACKGROUND

Oral lichen planus (OLP) is a relatively common, chronic inflammatory condition, which frequently presents with symptoms of pain and irritation. OLP is often difficult to manage. Therefore there is a need for more effective and safer therapies for symptomatic OLP.

OBJECTIVE

Our purpose was to determine the effectiveness of topical tacrolimus as therapy for symptomatic OLP.

METHODS

A retrospective review was performed of 13 patients with symptomatic OLP treated with topical tacrolimus between September 1999 and September 2000.

RESULTS

Eleven of the 13 patients reported definite symptomatic response to treatment and 2 had no response. Eight patients had a partial response, whereas 3 patients had a complete response with respect to lesion clearance. Seven of the responding patients had no flares with continued treatment. The other 4 patients noted flares soon after stopping the treatment. Side effects were rare and minor.

CONCLUSIONS

In this retrospective case series of 13 patients, topical tacrolimus was well tolerated and appeared to be an effective therapy to control symptoms and clear lesions of OLP.

Management of oral lichen planus

Lichen planus is a relatively common disorder of the stratified squamous epithelia. Most dental and medical practitioners see patients with lichen planus, but not all are recognized as having the disease. Patients with lichen planus may have concomitant involvement of the disease in multiple sites. Oral lichen planus lesions usually have a distinctive clinical morphology and characteristic distribution, but oral lichen planus may also present a confusing array of patterns and forms, and other disorders may clinically mimic oral lichen planus. The etiopathogenesis of lichen planus appears to be complex, with interactions between genetic, environmental, and lifestyle factors. Much has now been clarified about the etiopathogenic mechanisms involved and interesting new associations, such as with liver disease, have emerged. The management of lichen planus is still not totally satisfactory in all cases and there is as yet no definitive treatment that results in long term remission, but there have been advances in the control of the condition. Amongst the many treatments available, high potency topical corticosteroids remain the most reliably effective, though topical cyclosporine, topical tacrolimus, or systemic corticosteroids may be indicated in patients whose condition is unresponsive to topical corticosteroids.