Log in Register

Login to your account

Username *
Password *
Remember Me

Create an account

Fields marked with an asterisk (*) are required.
Name *
Username *
Password *
Verify password *
Email *
Verify email *
Captcha *

Captcha Image Reload image challenge


Oral Pathology

Authors: Dr. Sumanta Kumar, Dr. Virendra Kumar, Dr. Pratiksh Kumar.

Abstract:
Lichen planus (LP) is a chronic inflammatory disease of probable immune-based etiology. Patients with LP may be asymptomatic whereas most experience intense pruritus. It can present with a variety of clinical manifestations. It may affect the skin, mucous membranes or both. Often the arms, legs, back or inside of the mouth are affected; however it can also affect the genital area including the vagina or penis. LP may occasionally involve the nail, hair and scalp. It is possible to have the disease in one area without ever having a problem elsewhere. Spontaneous remission is rare. A proper history and diagnostic testing are necessary to obtaining an accurate diagnosis and its management. Here we are presenting a case of lichen planus with involvement of oral mucosa, skin, nail as well as genitalia.

Introduction:
Lichen planus (LP) is a chronic inflammatory disease of probable immune-based aetiology 1 affecting 1 to 2% of the population. Infectious (e.g. hepatitis C virus), autoimmune, metabolic, genetic or psychosomatic factors have been proposed to be involved in its aetiology. Predominant locations of skin involvement are flexure surfaces of wrists, anterior surface of the lower limbs, lumbar region,2 genitalia, and oral mucosa3. It can present with a variety of clinical manifestations4 and the lesions of LP may be described using the six (P’s): pruritic, polygonal, plane, purple papules and plaques. New lesions may develop in areas of trauma (Koebner phenomenon).5 As the disease affects both the oral and the genital area, physicians and dentists with special competence in oral medicine need to collaborate closely.6

Here we are presenting a case with skin, mucosal as well as genital involvement.

Case:
A 37 years old male patient reported to our department with deposits over teeth (Figure-1, A) and burning sensation of mouth during taking spicy food. Intraoral examination shows bilaterally grayish- white keatotic reticular radiating line present on 2nd and 3rd molar region of buccal mucosa (Figure-1, C&D).
1A 1B 1C 1D
Photograph showing stain deposit over lower anterior teeth. Skin eruptions, involving back of the neck. Showing radiating reticular keratotic lines over right and left buccal mucosa as well as grayish-white keratotic patches over tongue.

Dorsal surface of tongue also shows covered with thick grayish white keratotic pathches (Figure-1, C&D). On physical examination we discovered there are many pruiritic skin eruptions; involving back of the neck (Figure-1, B) and dorsal surface of hand (Figure-2, A). Nail changes are also noted in the form of elevated vertical ridges over nail with central depressed area (Figure-2, B). During taking personal history patient reveled, some lesion are also present over glans penis and they are sometimes painful. On examination we found grayish- white radiating lines are present with erosive area over glans penis as well as shaft (Figure-2, C). A provisional diagnosis lichen planus was made with involvement of Oral, cutaneous, and genatalia. Punch biopsy was taken from right buccal mucosa and send for histopatholgy; report confirm the diagnosis of Oral lichen planus (Figure-2, D).
2A 2B 2C 2D
Papular lesion over dorsal surface of hand. Thum showing, nail changes Grayish-white radiating lines are present with erosive area over glans penis as well as shaft

Discussion:
The dermatosis, lichen planus (LP) was first described by Erasmus Wilson in 18697. It is not caused by infection, hormonal changes or ageing. There may be a problem with immune system. In LP the system may be overactive, making proteins that cause inflammation in the skin, mouth or in the genital area8 Precipitating factors of OLP are, for example, particular foods, alcohol, smoking, dental plaque and poor oral hygiene. 9 Lichen planus is not contagious and cannot be passed to a sexual partner and there is no absolute cure for LP.8

The World Health Organization recognizes seven different clinical forms of OLP: reticular, papular, in plaques, atrophic, erosive, ulcerated, and bullous. The reticular pattern is considered the most common whereas the papular form of OLP is rare10. The classic presentation of LP involves the appearance of polygonal, flat-topped, violaceous papules and plaques. Superimposed, reticulated white scale, termed “Wickham’s striae”, may be appreciated on physical examination of oral or cutaneous LP4

Clinically, oral lichen planus (OLP) lesions are frequently bilateral but not always symmetrical. Buccal mucosa, dorsum of tongue and gingiva are usually affected 11 in present case buccal mucosa and tongue involvement seen.

Scalp LP presents with areas of hair loss with keratotic follicular papules and, if left untreated, these areas progress to scarring alopecia and re-growth of hair will not occur. 2 When LP involves hair follicles in a condition known as lichen planopilaris (LPP). Rare LPP variants include frontal fibrosing alopecia (scarring alopecia of the frontal scalp) and Graham–Little syndrome (triad of cicatricial alopecia of the scalp, nonscarring alopecia of the axillae and pubis, and perifollicular keratotic papules).4

Lichen planus may also involve the nail2. The most specific nail abnormality in LP is the formation of wedge-shaped deformity of the nail bed. Longitudinal ridging (similar nail changes is also affremed in our case), distal splitting, and thinning of the nail plate.8

Mucous membrane involvement of LP occurs in up to two-thirds of the cases, more often in the oral cavity than in the genitalia12. Vulvovaginal and penile lichen planus have been believed to be uncommon occurrences. The incidence of genital lichen planus is probably still underestimated because, first, physicians and dentists do not routinely examine the genitalia of their patients, and secondly, because genital lesions may be asymptomatic or subtle13. Fifty percent of women and 25% of men with cutaneous LP have genital involvement. 14 But in case having buccal mucosa, tongue, cutaneous, nail as well as genital involement.
In genital LP, lesions can be papulosquamous, hypertrophic or erosive12. Asymptomatic reticular vulvar lesions may also be present, but are rarely the sole manifestation of vulvovaginal LP.

LP of the male external genitalia commonly involves the glans penis, the lesions being typically annular. Violaceous flat-topped papules similar to lesions elsewhere in the skin can also occur on the glans and shaft of the penis. The lesions may develop as arcuate groupings of individual papules that evolve into rings of clustered papules with central clearing. Fine white streaks are usually visible on the surface of the lesions (Wickham striae). Solitary lichen planus of the glans penis alone is very rare.3

The cutaneous form of lichen planus usually subsides within 2 - 4 years; mucosal lesions tend to be more chronic, resulting in long-lasting itching and pain. Scarring is not uncommon and may lead to major anatomical changes. As a consequence of these anatomical changes, normal sexual activity is often impossible12.

Erosive lichen planus has been reported to eventuate in the formation of squamous cell carcinoma. Although uncommon, this transformation can clearly occur in the mouth, on the vulva, and on the penis.13

There are many treatments used to treat LP8. The first-line treatments of OLP are topically applied corticosteroid ointments. Second choice therapy would be the use of systemic corticosteroids for symptom control. Topical and systemic cyclosporin A has also been used successfully.15

REFERENCE:
  1. Abdel-Latif A M, Abuel-Ela H A, El-Shourbagy SH. Increased caspase-3 and altered expression of apoptosis-associated proteins, Bcl-2 and Bax in lichen planus. Clinical and Experimental Dermatology. 2008;34:390–395.
  2. Stojanovič L, Lunder T, Rener-Sitar K, Mlakar B, Matičič M. Thorough Clinical Evaluation of Skin, as well as Oral, Genital and Anal Mucosa is Beneficial in Lichen Planus Patients. Coll. Antropol. 2011;35(1):15-20.
  3. Karthikeyan K, Jeevankumar B, Thappa DM. Bullous lichen planus of the glans penis. Dermatology Online Journal. 2003;9(5):31.
  4. Lehman JS, Tollefson MM, Gibson LE. Review Lichen Planus. International Journal of Dermatology. 2009;48:682-694.
  5. Ruest A, Khachemoune A. Lichen Planus. Dermatology Nursing. 2007;19(6):563.
  6. Lundqvist EN, Wahlin YB, Bergdahl M, Bergdahlg J. Psychological health in patients with genital and oral erosive lichen planus.JEADV.2006;20:661–666.
  7. Kanwar AJ, De D. Lichen planus in children. Indian J Dermatol Venereol Leprol. 2010; 76(4):366-372.
  8. Kaur P, Ahmed F, Sharma P, Mane P, Atre K, Mayee R. International Journal of Universal Pharmacy and Life Sciences.2011;1(1):155-162.
  9. Dissemond J. Oral lichen planus: an overview. Journal of Dermatological Treatment. 2004;15:136–140.
  10. Jacques CDeMC, Pereira ALC, Cabral MG, Odont D, Cardoso AS, Ramos-e-Silva M. Oral Lichen Planus Part I: Epidemiology, Clinics, Etiology, Immunopathogeny, and Diagnosis. SKINmed. 2003;2:342-349.
  11. Crincoli V, Bisceglie MBDi, Scivetti M, Lucchese A, Tecco S, Festa F. Oral lichen planus: update on etiopathogenesis, diagnosisand treatment. Immunopharmacology and Immunotoxicology. 2011;33(1):11–20.
  12. Helgesen ALO, Gjersvik P, Jebsen P, Kirschner R, Tanbo T. Vaginal involvement in genital erosive lichen planus. Acta Obstetricia et Gynecologica. 2010;89:966–970.
  13. Moyal –Barracco M & Edwards L. Diagnosis and therapy of anogenital lichen planus. Dermatologic Therapy. 2004,(17):38–46.
  14. McPherson T, Cooper S. Vulval lichen sclerosus and lichen planus. Dermatologic Therapy. 2010;23:523–532.
  15. Dissemond P. Oral lichen planus: an overview. Journal of Dermatological Treatment. 2004; 15:136–140.