Mucocutaneous Diseases

Question 1

Demographic of lichen planus?

Answer 1

0.5-2% of the population

4th-8th decade

60% women

Can affect children (2-3%)

Europeans/Indians > Chinese/Malay

Question 2

How long are LP skin lesions active for?

Answer 2

Around 18 months on average

Question 3

Aetiology of lichen planus?

Answer 3

Unknown, may be autoimmune or related to stress, spicy foods, diabetes or liver disease

Question 4

Symptoms of OLP?

Answer 4

Asymptomatic

Pain & discomfort especially when eating spicy/ acidic/ citrus foods or brushing teeth

Time present varies

Pts may have concerns about appearance especially if lips & gingiva involved

Lesions often in areas of increased friction (koebner phenomenon)

Question 5

7 types of presentation of OLP?

Answer 5

1. Reticular
2. Atrophic (erythematous)
3. Erosive (ulcerative)
4. Papular
5. Bullous
6. Plaque like
7. Circinate

Question 6

Extra-oral symptoms of LP?

Answer 6

Cutaneous (15%)
- Purple polygonal pruritic papules
- Symmetrical distribution, on flexor surfaces of wrists/shins or sites of trauma (Koebner phenomenon)
- Surface network of fine white striations “Wickham’s striae”

Dystrophic nails (10%)
- Longitudinal grooving & pitting & can get complete nail loss

Vulvovaginal-gingival syndrome
- Ulcerative, symptomatic LP on gingiva, vulva & vagina
- Progressive vulval disease leading to scarring

Hair
- Lichen planopilaris (affecting scalp) => scarring alopecia

Question 7

Differential diagnoses of oral lichenoid lesions?

Answer 7

Lichenoid reactions
Dysplasia
Leukoplakia
Keratosis
DLE
GVHD
Gingival form - i.e. desquamative gingivitis - PV, MMP

Question 8

What should patient’s be informed of when diagnosed with OLP?

Answer 8

That there is risk of malignant transformation (~0.5-2%)

Pts should ‘monitor’ disease & attend dentist regularly

Question 9

How to manage symptomatic LP?

Answer 9

Eliminate provoking factors (e.g. mechanical trauma from sharp cusp/ill-fitting denture)

Reduce chemical irritation (spicy/acidic food & SLS-free toothpaste in desquamative gingivitis)

Good OH & alcohol-free/CHX mouthwash

Question 10

How to manage asymptomatic LP?

Answer 10

Reassure pt & review

Pt should be informed of malignant risk & encouraged to attend regularly

Pt should be made aware lesions may develop outside the mouth

Advise to:
- Maintain good OH
- Smoking cessation

Question 11

1st line drugs for LP?

Answer 11

Topical corticosteroids
- Hyrocortisone, betamethasone or benzydamine (Difflam)

Systemic
- Prednisolone or deflazacort

Question 12

2nd line drugs for LP?

Answer 12

Topical calcineurin inhibitors (immunosuppressants)

• Calcineurin
• Ciclosporin
• Tacrolimus
• Pimecrolimus

Question 12

What drugs would be given for severe LP?

Answer 12

Systemic corticosteroids

Ciclosporin

Azathioprine

Mycophenolate mofetil

Dapsone

Thalidomide

Question 13

What is lichenoid reaction?

Answer 13

Similar in clinical presentation & histology to LP but more defined aetiology

Question 14

Aetiology of lichenoid reaction?

Answer 14

Drug induced

or

Dental material related

Question 15

Clinical presentation of lichenoid reaction?

Answer 15

Similar to LP but likely to be erosive form (soreness) & affect palate/tongue

Unilateral/bilateral, may be asymmetric if reacting to specific materials

May be ulcerative

Question 16

Aetiology of lichenoid reaction?

Answer 16

Drug-induced:
- Beta-blockers
- ACE inhibitors
- Diuretics
- NSAIDs
- Gold salts
- Methyldopa
- Oral hypoglycaemics
- Pencillamine
- Anti-malarial
- Allopurinol

Dental material induced
- Metallic restorative materials (e.g. gold/ amalgam/ nickel)
- Resins (BisGMA)

Question 17

Histopathology of lichen planus?

Answer 17

+/- Hyperkeratosis

Saw-tooth rete ridges in epidermis

Basal cell liquefaction/ degeneration

Lymphocyte-dominant subepithelial band

Question 18

Histology of lichenoid reaction?

Answer 18

Same as LP

Deeper & less well-defined infiltrate

Large number of plasma cells & eosinophils

Question 19

Management of lichenoid reaction?

Answer 19

Good drug history - if possible, withdraw drug & monitor

Local cause - patch test

Manage as LP until resolves

Question 20

What is discoid lupus erythematosus?

Answer 20

Chronic indolent cutaneous & oral disorder => scaly skin patches in sun-exposed areas & LP-like oral lesions

Question 21

Aetiology of DLE?

Answer 21

AI disorder - autoantibodies & cell-mediates immunity against normal cellular components

May be precipitated by drugs, environmental, hormonal or viral factors

Question 22

Oral presentation of DLE?

Answer 22

Similar to oral LP - bilateral on labial, buccal or alveolar mucosa or vermillion border but also palate lesions present (rare in LP)

Less well-demarcated erythematous areas surrounded by border of fine white striae

May ulcerate - esp. in active lesions or cases progressing to SLE

Question 23

Cutaneous presentation of DLE?

Answer 23

Scaly atrophic plaques on sun-exposed skin (sun protection is vital)

One or more oval plaques (red & scaly with keratin plugs) - may involve oral & genital mucosa, skin & hair

Well-demarcated, red, atrophic, scaly & show keratin plugs in dilated follicles generalised telangiestasia

Scarring => Alopecia & pigementation on scalp

Question 24

Management of DLE?

Answer 24

Oral lesions as with LP

Cutaneous lesions = suncream (SPF 50) & chloroquine & potent steroids