Managing Lichen Planus Flashcards
Contributing factors to LP
- idiopathic
- may be due to medication, ie: anti-hypertensive
- amalgam restoration
Common medication related to LP
- ACE inhibitors
- Beta- adrenergic blockers
- Diuretics - Bendroflumethiazide, Frusemide
- NSAIDs
- DMARDs-
Disease-modifying antirheumatic drugs, ie: Penicillamine, Gold, Sulphasalazine
Rare
- phenothiazines
How does Lichenoid drug reaction present?
- more often widespread lesions
- often bilateral and mirrored
- poorly responsive to standard steroid tx
what to consider when giving drug
- benefit of drug
- risk of stopping drug
- discomfort from symptoms
- degree of tx needed
Risk/ benefit analysis
- does the benefit of stopping the drug > risk to pt’s health
- mild lichen symptoms: unlikely
- significant symptoms: where maximum topical/ systemic tx is needed to control lichen symptoms
How to manage medication change?
- discuss with pt’s GP
- maybe medicine no longer needed
- easy change of medication , ie: ACE inhibitor to AT2 blocker; same reactions to BP
Amalgam related lesions
- there is lichenoid change when teeth are in occlusion
- always check during oral examination
- if unsure what trigger LP; ie: amalgam, mercury
- do a patch test to amalgam/ mercury
- pragmatic approach is to remove restoration, but not always sensible/ practical
- might respond when remove/ not; might cause more damage to tooth, hence patch test first
Managing amalgam related lesion
If not symptomatic, do nothing
- potentially malignant lesion? low malignant tranformative risk
- replacing restoration may cause increase tooth damage
- cost to pt -> DPB will fund composite
- amalgam should only be changed if direct contact with lichenoid reactions
Amalgam should be replaced with?
- composite
- glass
- gold: low palladium alloy (PMA)
What to be aware of when removing amalgam?
- rubber dam
- high volume suction
- PPI- personal protection equipment
- avoid doing during pregnancy
Lichen planus Management
- Removal of cause
- medicines
- dental restorations, ie: amalgam - Biopsy
- if not clear, then biopsy
- useful in asymptomatic lesions to ahve an establish diagnosis - Blood test
- more symptomatic if pt is haematinics deficiency
- FBC
- if lupus suspected, need autoantibody screen (ANA, Ro, dsDNA) will be sensible
How to manage mild intermittent lesions
- Topical OTC lesions
- Chlorhexidine MW
- Benzdamine MW - Avoid SLS containing toothpaste- driver for gingival lesions
- Sensodyne Pronamel
- Kingfisher
Manage persisting symptomatic lesions (SDCEP guidance)
Primary care setting
- Topical steroids (oral ulcers)
1. Beclomethasone MDI 0.5mg/ puff - 2 puffs 2-3 times daily
- Bethamethasone MW rinse- 1mg/ 10ml/ 2 mins/ twice daily
- pt should restart medication if becomes symptomatic
Hospital setting (specialist)
- higher strength topical steroids- puffer/ rinse
- skin steroid cream - Clobetasol
- can be applied in a veneer form for gingival lesion
- Topical tacrolimus -> ointment/ MW (more active ingredient to active lesions)
- Hydroxychloroquine (effective immune modulator for both cutaneous and oral LP)
- systemic immunemodulators, ie: Azathioprine, Mycophenolate
Gingival veneer for topical steroid
gel form Synalar
Graft vs Host disease
- due to bone transplant
- give lesions similar to lichenoid lesions
- histologically similar to LP, lymphocytic and change in keratinisation and prickle cell layers
- ask if pt has organ transplant recently
Lupus erythematosis
- if palatal lesions are found, lupus must always be considered
- associated with systemic autoantibodies
Lupus erythematosis histology
- infiltration of lymphocytes far from basement membrane
