Oral lichen planus
Encyclopedia
Mucosal lichen planus, or oral lichen planus (OLP), is an inflammatory
auto-immune disease
that affects oral mucosa
, with or without the involvement of the skin
and other mucous membrane
s.
and does not involve any known pathogen
.
OLP has been reported as a complication of chronic hepatitis C
virus infection and can be a sign of chronic graft-versus-host disease
of the mucous membrane (and skin).
It has been suggested that OLP may respond to stress
, where lesions may present on the mucosa (or skin) during times of stress in those with the disease.
Lichen planus may also affect the genital mucosa - vulvovaginal-gingival lichen planus. It can resemble other skin conditions such as atopic dermatitis
and psoriasis
.
Rarely, lichen planus shows esophageal involvement, where it can present with erosive esophagitis and stricturing. It has also been hypothesized that it is a precursor to squamous cell carcinoma of the esophagus.
A biopsy
is useful in identifying histological features that help differentiate OLP from these conditions, except of the histollogy identical lichenoid reaction lesion (including lichenoid reaction of graft-versus-host disease
). Frictional keratosis and morsicatio buccarum can and should be diagnosed clinically without histo-pathlogical examination.
speciality. It is generally accepted that OLP (as well as other mucous membrane lichen planus, such as genital) is more difficult to manage than skin lichen planus.
Currently there is no cure for lichen planus but there are certain types of medicines used to reduce the effects of the inflammation. Lichen planus may go into a dormant state after treatment. There are also reports that lichen planus can flare up years after it is considered cured.
Medicines used to treat lichen planus include:
Non-drug treatments:
Inflammation
Inflammation is part of the complex biological response of vascular tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. Inflammation is a protective attempt by the organism to remove the injurious stimuli and to initiate the healing process...
auto-immune disease
Disease
A disease is an abnormal condition affecting the body of an organism. It is often construed to be a medical condition associated with specific symptoms and signs. It may be caused by external factors, such as infectious disease, or it may be caused by internal dysfunctions, such as autoimmune...
that affects oral mucosa
Oral mucosa
The oral mucosa is the mucous membrane epithelium of the mouth. It can be divided into three categories.*Masticatory mucosa, para-keratinized stratified squamous epithelium, found on the dorsum of the tongue, hard palate and attached gingiva....
, with or without the involvement of the skin
Skin
-Dermis:The dermis is the layer of skin beneath the epidermis that consists of connective tissue and cushions the body from stress and strain. The dermis is tightly connected to the epidermis by a basement membrane. It also harbors many Mechanoreceptors that provide the sense of touch and heat...
and other mucous membrane
Mucous membrane
The mucous membranes are linings of mostly endodermal origin, covered in epithelium, which are involved in absorption and secretion. They line cavities that are exposed to the external environment and internal organs...
s.
Epidemiology
OLP affects women more than men (at a ratio of 3:2), and occurs most often in middle-aged adults. OLP in children is rare.Cause
The cause of lichen planus is not known. It is not contagiousContagious disease
A contagious disease is a subset category of infectious diseases , which are easily transmitted by physical contact with the person suffering the disease, or by their secretions or objects touched by them....
and does not involve any known pathogen
Pathogen
A pathogen gignomai "I give birth to") or infectious agent — colloquially, a germ — is a microbe or microorganism such as a virus, bacterium, prion, or fungus that causes disease in its animal or plant host...
.
OLP has been reported as a complication of chronic hepatitis C
Hepatitis C
Hepatitis C is an infectious disease primarily affecting the liver, caused by the hepatitis C virus . The infection is often asymptomatic, but chronic infection can lead to scarring of the liver and ultimately to cirrhosis, which is generally apparent after many years...
virus infection and can be a sign of chronic graft-versus-host disease
Graft-versus-host disease
Graft-versus-host disease is a common complication after a stem cell transplant or bone marrow transplant from another person . Immune cells in the donated marrow or stem cells recognize the recipient as "foreign". The transplanted immune cells then attack the host's body cells...
of the mucous membrane (and skin).
It has been suggested that OLP may respond to stress
Stress (medicine)
Stress is a term in psychology and biology, borrowed from physics and engineering and first used in the biological context in the 1930s, which has in more recent decades become commonly used in popular parlance...
, where lesions may present on the mucosa (or skin) during times of stress in those with the disease.
Clinical presentation
OLP may present in one of three forms.- The reticular form is the most common presentation and manifests as white lacy streaks on the mucosa (known as Wickham's striae) or as smaller papules (small raised area). The lesions tend to be bilateral and are asymptomatic. The lacy streaks may also be seen on other parts of the mouth, including the gingiva (gums), the tongue, palate and lips.
- The bullous form presents as fluid-filled vesicles which project from the surface.
- The erosive form presents with erythematous (red) areas that are ulcerated and uncomfortable. The erosion of the thin epithelium may occur in multiple areas of the mouth, or in one area, such as the gums, where they resemble desquamative gingivitisDesquamative gingivitisDesquamative gingivitis is a cutaneous condition characterized by diffuse gingival erythema with varying degrees of mucosal sloughing and erosion.A band of red atrophic or eroded mucosa affecting the attached gingiva is known as dequamative gingivitis...
. Wickham's striae may also be seen near these ulcerated areas. This form may undergo malignant transformation.
Lichen planus may also affect the genital mucosa - vulvovaginal-gingival lichen planus. It can resemble other skin conditions such as atopic dermatitis
Atopic dermatitis
Atopic dermatitis is an inflammatory, chronically relapsing, non-contagious and pruritic skin disorder...
and psoriasis
Psoriasis
Psoriasis is an autoimmune disease that appears on the skin. It occurs when the immune system mistakes the skin cells as a pathogen, and sends out faulty signals that speed up the growth cycle of skin cells. Psoriasis is not contagious. However, psoriasis has been linked to an increased risk of...
.
Rarely, lichen planus shows esophageal involvement, where it can present with erosive esophagitis and stricturing. It has also been hypothesized that it is a precursor to squamous cell carcinoma of the esophagus.
Histo-pathological appearance
The microscopic appearance of lichen planus is pathognomonic for the condition- Hyperparakeratosis with thickening of the granular cell layer
- Development of a "saw-tooth" appearance of the rete pegs
- Degeneration of the basal cell layer
- Infiltration of inflammatoryInflammationInflammation is part of the complex biological response of vascular tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. Inflammation is a protective attempt by the organism to remove the injurious stimuli and to initiate the healing process...
cellsWhite blood cellWhite blood cells, or leukocytes , are cells of the immune system involved in defending the body against both infectious disease and foreign materials. Five different and diverse types of leukocytes exist, but they are all produced and derived from a multipotent cell in the bone marrow known as a...
into the subepithelial layer of connective tissue
Differential Diagnosis
The clinical presentation of OLP may also resemble other conditions, including:- Lichenoid drug reaction. This entity is identical to OLP both clinically and histologically. However, lichenoid lesions may be single (in comparison to the usual bilateral appearance of OLP) with proximity to amalgam (metal alloys) dental restoration.
- Other oral vesiculo-ulcerative conditions such as Pemphigus vulgarisPemphigus vulgarisPemphigus vulgaris is a chronic blistering skin disease with skin lesions that are rarely pruritic, but which are often painful.-Pathophysiology:...
and Benign mucous membrane pemphigoid - Discoid lupus erythematosusDiscoid lupus erythematosusDiscoid lupus erythematosus is an uncommon autoimmune disease of the basal cell layer of the skin. It occurs in humans and cats, more frequently occurring in dogs. It does not progress to systemic lupus erythematosus in dogs. SLE can also have skin symptoms, but it appears that the two are...
- Chronic ulcerative stomatitis
- Frictional keratosisKeratosisKeratosis is a growth of keratin on the skin. More specifically, it can refer to:* actinic keratosis * hydrocarbon keratosis* keratosis pilaris , also known as * seborrheic keratosis-See also:...
and Morsicatio buccarumMorsicatio buccarumMorsicatio buccarum is a cutaneous condition characterized by chronic irritation or injury to the buccal mucosa from repetitive chewing, biting or nibbling produces characteristic changes in the tissue....
(chronic cheekCheekCheeks constitute the area of the face below the eyes and between the nose and the left or right ear. They may also be referred to as jowls. "Buccal" means relating to the cheek. In humans, the region is innervated by the buccal nerve...
biting) - Oral leukoplakiaLeukoplakiaLeukoplakia is a clinical term used to describe patches of keratosis. It is visible as adherent white patches on the mucous membranes of the oral cavity, including the tongue, but also other areas of the gastro-intestinal tract, urinary tract and the genitals. The clinical appearance is highly...
- Chronic graft-versus-host-disease may manifest as lichenoid reactionLichenoid reaction of graft-versus-host diseaseLichenoid reaction of graft-versus-host disease presents with chronic graft-versus-host disease, characterized by a lichenoid eruption indistinguishable clinically and histologically from lichen planus. This type of lichenoid lesions have a higher risk of malignant transformation to oral squamous...
. This type of lichenoid lesions have a higher risk of malignant transformationMalignant transformationMalignant transformation is the process by which cells acquire the properties of cancer. This may occur as a primary process in normal tissue, or secondarily as malignant degeneration of a previously existing benign tumor....
to oral squamous cell carcinomaSquamous cell carcinomaSquamous cell carcinoma , occasionally rendered as "squamous-cell carcinoma", is a histologically distinct form of cancer. It arises from the uncontrolled multiplication of malignant cells deriving from epithelium, or showing particular cytological or tissue architectural characteristics of...
in comparison to the classical oral lichen planus. Graft-versus-host-disease-associated oral cancerOral cancerOral cancer is a subtype of head and neck cancer, is any cancerous tissue growth located in the oral cavity. It may arise as a primary lesion originating in any of the oral tissues, by metastasis from a distant site of origin, or by extension from a neighboring anatomic structure, such as the...
may have more aggressive behavior with poorer prognosis, when compared to oral cancer in non-hematopoietic stem cell transplantation patients.
A biopsy
Biopsy
A biopsy is a medical test involving sampling of cells or tissues for examination. It is the medical removal of tissue from a living subject to determine the presence or extent of a disease. The tissue is generally examined under a microscope by a pathologist, and can also be analyzed chemically...
is useful in identifying histological features that help differentiate OLP from these conditions, except of the histollogy identical lichenoid reaction lesion (including lichenoid reaction of graft-versus-host disease
Lichenoid reaction of graft-versus-host disease
Lichenoid reaction of graft-versus-host disease presents with chronic graft-versus-host disease, characterized by a lichenoid eruption indistinguishable clinically and histologically from lichen planus. This type of lichenoid lesions have a higher risk of malignant transformation to oral squamous...
). Frictional keratosis and morsicatio buccarum can and should be diagnosed clinically without histo-pathlogical examination.
Treatment
Care of OLP is within the scope of Oral medicineOral medicine
Oral medicine is the dental specialty placed at the interface between medicine and dentistry.- Scope :Oral medicine is concerned with diagnosis and non-surgical management of non-dental pathology affecting the oral and maxillofacial region, such as oral lichen planus, Behçet's disease and pemphigus...
speciality. It is generally accepted that OLP (as well as other mucous membrane lichen planus, such as genital) is more difficult to manage than skin lichen planus.
Currently there is no cure for lichen planus but there are certain types of medicines used to reduce the effects of the inflammation. Lichen planus may go into a dormant state after treatment. There are also reports that lichen planus can flare up years after it is considered cured.
Medicines used to treat lichen planus include:
- Oral and topicalTopicalIn medicine, a topical medication is applied to body surfaces such as the skin or mucous membranes such as the vagina, anus, throat, eyes and ears.Many topical medications are epicutaneous, meaning that they are applied directly to the skin...
steroids. - Oral retinoids
- immunosuppressantImmunosuppressantAn immunosuppressant is any substance that performs immunosuppression of the immune system. They may be either exogenous, as immunosuppressive drugs, or endogenous, as ,e. g., testosterone...
medications - hydroxychloroquineHydroxychloroquineHydroxychloroquine is an antimalarial drug, sold under the trade names Plaquenil,Axemal, Dolquine, and Quensyl, also used to reduce inflammation in the treatment of rheumatoid arthritis and lupus...
- tacrolimusTacrolimusTacrolimus is an immunosuppressive drug that is mainly used after allogeneic organ transplant to reduce the activity of the patient's immune system and so lower the risk of organ rejection...
- dapsoneDapsoneDapsone is a medication most commonly used in combination with rifampicin and clofazimine as multidrug therapy for the treatment of Mycobacterium leprae infections . It is also second-line treatment for prophylaxis against Pneumocystis pneumonia caused by Pneumocystis jiroveci Dapsone...
- Aloe veraAloe veraAloe vera, pronounced , also known as the true aloe or medicinal aloe, is a species of succulent plant in the genus Aloe that is believed to have originated in the Sudan. Aloe vera grows in arid climates and is widely distributed in Africa, India, Nepal and other arid areas.The species is...
- Pusley Portulaca oleracea
Non-drug treatments:
- UVB NarrowBand Phototherapy