managing lichen planus

Question 1

When is something termed a lichenoid reaction?

Answer 1

When the cause of the lichen planus is known, the oral lesion is termed a lichenoid reaction to that specific cause

Question 2

Name 4 medications that commonly cause lichen planus

Answer 2

Any from:
- ACE inhibitors
- Beta blockers
- Diuretics
- NSAIDs
- DMARDs

Question 3

Which DMARDs are associated with lichen planus?

Answer 3

Penicillamine
Gold
Sulphasalazine

Question 4

Describe lichenoid drug reactions

Answer 4

More often widespread lesions
Often bilateral and mirrored
Often poorly responsive to standard steroid treatment

Question 5

How are lichenoid drug reactions managed?

Answer 5

Consider benefit of drug to patient against risk of stopping drug
If mild symptoms then unlikely advantage to stopping medication
If significant symptoms then probably advantage to stopping drugs
If in doubt discuss with patient’s GP

Question 6

Give an example of a medication change for patients with a lichenoid drug reaction

Answer 6

Changing ACE inhibitors to an angiotensin II blocker

Question 7

How should amalgam related lichenoid lesions be treated?

Answer 7

Patch test to amalgam can be carried out
Consider removing the restoration (not always practical)

Question 8

How is lichen planus managed?

Answer 8

Remove any causes - medicines and restorations
Biopsy essential unless good reason not to
Blood tests - haematinics, FBC, if lupus suspected then antibody screen (ANA, anti Ro)

Question 9

How are mild, intermittent lichen planus lesions treated?

Answer 9

Chlorhexidine mouthwash
Benzdamine mouthwash
Avoid SLS containing toothpaste

Question 10

How should persisting symptomatic lichen planus lesions be managed in a primary care setting?

Answer 10

Topical steroids for ulcers
Beclometasone MDI inhaler
Betamethasone rinse

Question 11

How should persisting symptomatic lesions be treated in a hospital setting?

Answer 11

Higher strength topical steroids
Topical tacrolimus - ointment or mouthwash
Hydroxychloroquine
Systemic immunomodulators - azathioprine and mycophenolate

Question 12

How can gingival veneers be used as topical steroids?

Answer 12

Vacuum formed device with steroid cream inserted into it

Question 13

Describe graft vs host disease?

Answer 13

Similar to lichen planus
Lymphocytic band seen along basement membrane
Oral GVHD is systemic and will be happening in other body systems and organs

Question 14

Compare lichen planus to lupus erythematosus

Answer 14

If palatal lesions found, lupus should always be considered
When solitary lesion in oral mucosa, it is termed discoid lupus
When associated with systemic autoantibodies, it is termed systemic lupus erythematosus

Question 15

Give 2 examples of lichen-like lesions?

Answer 15

GVHD
Lupus erythematosis

Question 16

Describe lupus erythematosus histologically

Answer 16

Intense lymphocytic infiltrate deeper in connective tissue and away from the basement membrane

Question 17

How should lichen-like lesions be treated if there is diagnosis of a systemic condition, but only oral lesions are present?

Answer 17

Treat symptomatically as lichen planus but liaise with physician regarding oral lesions in overall context of patients health