Lichen Planus

Question 1

What are the different clinical presentations of LP

Answer 1

Reticular

Atrophic/erosive

ulcerative

Question 2

What is LP

Answer 2

Tcell immune response to langerhan cells presenting an antigen and activatinf the immune response where the T cells bind and induce inflam. response

Question 3

Histologically what is commonly seen in LP

Answer 3

Clear and classical T-cell infiltrate into the basement membrane area with a lymphocytic band hugging the basement membrane

Chronic Inflammatory cell infiltrate

Saw tooth rete ridges

Basal cell damage

Patchy acanthosis

Parakeratosis

Civatte bodies (dead keratinocytes)

Question 4

What is difference between Oral Lichen Planus and Oral Lichenoid Tissue Reaction

Answer 4

Oral Lichen Planus: generalised and idiopathic

Oral Lichenoid Tissue Reaction: localised and may be a response to meidicnes/allergens

Question 5

If a patient has a Oral Lichen Planus/Oral Lichenoid Tissue Reaction what questions are important to ask

Answer 5

ask about systemic symptoms or recent cancer therapy:

Lupus

Graft versus host disease

Question 6

What is acanthosis

Answer 6

diffuse epidermal hyperplasia caused by the increased thickness of the stratum spinosum constituted by the prickle cells

Question 7

What are the potetional causes of LP

Answer 7

Lymphocyte activation and Attempt to remove chronic irritation

Genetic predisposition

Physical and emotional stress
Injury to the skin; lichen planus often appears where the skin has been scratched or after surgery — this is called the isomorphic response (koebnerisation)

Localised skin disease such as herpes zoster—isotopic response

Systemic viral infection, such as hepatitis C (which might modify self-antigens on the surface of basal keratinocytes)

Contact allergy, such as to metal fillings in oral lichen planus

Drugs; gold, quinine, b-bloakcers, ace inhibitors

Question 8

What drugs are thought to potetionaly cause OLR

Answer 8

Drugs causing OLR: Antihypertensives, Antimalarials, NSAIDS, Allopurinol, Lithium

Question 9

How many pt have other areas affected

Answer 9

50%

Question 10

What sites can LP appear

Answer 10

Buccal mucosa

Gingivae

Tongue – lateral aspect, dorsum

Lips

Palate

Question 11

Whats the most common site of LP

Answer 11

Buccal mucosa

Question 12

What is LP on the gingivae called and look like

Answer 12

desquamative gingivitis

very erythematous appearance (Similar clinical appearance to gingival pemphigoid and to plasma cell gingivitis)

Question 13

How to treat Gingivae LP

Answer 13

OH very important in settling lesion
-Especially interdental
-Seems plaque driven in many patients

Question 14

What are thought to be contributing factors to LP

Answer 14

Most are IDIOPATHIC – no known cause

Some related to MEDICATION

Some related to AMALGAM restorations

Question 15

What medications can cause LP

Answer 15

ACE inhibitors

Beta-adrenergic blockers

Diuretics – Bendroflumethiazide, frusemide

NSAIDs

DMARDs -Penicillamine, Gold, Sulphasalazine

Question 16

What do lichenoid drug reactions look like

Answer 16

More often widespread lesions

Often bilateral and mirrored

Often poorly responsive to standard steroid treatment

Question 17

How would you manage LP

Answer 17

Remove any cause:
-Medicines

-Dental restorations

-Biopsy to get clear diagnosis

-Blood tests; Haematinincs, FBC, If lupus suspected autoantibody screen (ANA, Ro, dsDNA)

Question 18

What would be management of OLP/OLR be

Answer 18

Symptomatic relief:

-Simple mouthwash (HSMW )
-Local anaesthetic (Benzydamine or lidocaine)
-Avoid trigger factors: Spicy foods, fizzy drinks
-Steroid mouthwash (Betamethasone m/w, beclometasone inhaler or hydrocortisone oromucosal tablets)
-Change restorations
-Onward Referral- Biopsy, inform of increased cancer risk, stopping the cause in OLR

Question 19

How can you treat mild LP

Answer 19

over the couter remedies:
-Chlorhexidene m/w
-Benzdamine m/w

Avoid SLS containing toothpastes
-Sensodyne

Question 20

How would you treat persisting symptomatic lesions

Answer 20

Clinical setting:
Topical steroids (as for Oral Ulcers)
-Beclomethasone MDI 0.5mg/puff – 2 puffs x 2-3 daily
-Betamethasone rinse – 1mg/10ml/2mins/twice daily

Hospital setting:
-Higher strength topical steroids

-‘Skin’ Steroid Cream – CLOBETASOL
Cream can be applied in a ‘veneer’ for gingival lesions

-Topical tacrolimus – ointment or mouthwash

-Hydroxychloroquine

-Systemic immunmodulators; Azathioprine, mycophenolate

Question 21

What diseases can produce LP like lesions

Answer 21

graft versus host disease

lupus erythematosus