Derm Dx: Denuded, crusted patches on the lower lip - Clinical Advisor

Derm Dx: Denuded, crusted patches on the lower lip

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A patient, aged 46 years, presented with denuded and crusted patches on his lower lip. The condition had waxed and waned in intensity over the past three years and has not responded to a three-week course of topical fluocinonide ointment.

When flared, the patient reported the condition was extremely painful. The patient tested positive for hepatitis C. He smoked cigarettes until two years ago.

Examination of the skin and nails revealed no additional untoward findings.

Biopsy of the lower lip revealed lichen planus, a condition that may affect multiple body sites including the mucous membranes, hair follicles, and nails.1 The prevalence has been reported to range from under 1% in North Americans to as high...

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Biopsy of the lower lip revealed lichen planus, a condition that may affect multiple body sites including the mucous membranes, hair follicles, and nails.1

The prevalence has been reported to range from under 1% in North Americans to as high as 3% in Asians.2


Oral lichen planus (OLP) usually occurs in conjunction with the classic skin findings of flat-topped violaceous papules characteristically found on the ankles and wrists. Localization solely to the lips, as in this case, is rare.3 Links to both cigarette smoking4 and hepatitis C5 infection have been suggested.

The most common clinical presentation of oral lichen planus is that of a white lace-like slightly elevated pattern with or without papules on the buccal mucosa. Other manifestations may include ulcerations, atrophic lesions, plaques or bullae. Usually asymptomatic, patients may complain of pain and soreness, especially if the lesion is ulcerated or eroded.1

Non-ulcerated lichen planus of the lips presents as leukoplakic patches that can be mistaken for actinic chelitis.6 Distinction between these conditions is made with historical clues and biopsy which, in the case of OLP, reveals a band-like lymphocytic infiltrate, necrotic keratinocytes, and dermal melanophages.7


It is important to diagnose lichen planus affecting the lips, as patients with this condition have an increased risk of malignant transformation to squamous cell carcinoma.8 First-line therapy of OLP involves good oral hygiene, cessation of tobacco products, and application of a topical steroid.

Additional therapies that may prove of value for resistant cases include topical calcineurin inhibitors9 and cyclosporine10 as well as low-level lasers11. Chronic, refractory disease warrants close observation and periodic biopsy to rule out neoplasia.

Megha Patel, BS, is a medical student at the Commonwealth Medical College.

Stephen Schleicher, MD, is an associate professor of Medicine at the Commonwealth Medical College and an Adjunct Assistant Professor of Dermatology at the University of Pennsylvania Medical College. He practices dermatology in Hazleton, PA.

References

  1. Scully C, Beyli M, Ferreiro MC, et al. Critical Reviews in Oral Biology & Medicine.  1998; 9(1): 86-122.  doi: 10.1177/10454411980090010501
  2. McCartan BE, Healy CM. J Oral Pathol Med 2008; 37:447.
  3. Cecchi R, Giomi A. Australasian Journal of Dermatology.  2002; 43: 309-310. 
  4. Meir Gorsky, Joel B Epstein, Haya Hasson-Kanfi, and Eliezer Kaufman. Tob Induc Dis. 2004. 2 (1). 9
  5. Carrozzo M, Scally K. World Journal of Gastroenterology. 2014; 20(24): 7534-7543.  doi: 10.3748/wjg.v20.i24.7534
  6. Swanson E, Bruce A, Camilleri M. Journal of the American Academy of Dermatology. 2009; 60(3): AB43. doi http://dx.doi.org/10.1016/j.jaad.2008.11.209.
  7. Francisca Fernández-González, Rocío Vázquez-Álvarez, Dolores Reboiras-López, Pilar Gándara-Vila, Abel García-García, José-Manuel Gándara-Rey. Med Oral Patol Oral Cir Bucal. 2011 Aug 1;16 (5):e641-6.
  8. Morente GB, Peinado CM, Colmenero CG, et al. Journal of the American Academy of Dermatology. 2014; 79 (5): AB137. doi: http://dx.doi.org/10.1016/j.jaad.2014.01.568
  9. Passeron T, Lacour JP, Fontas E, Ortonne JP. Arch Dermatol. 2007; 143:472.
  10. Conrotto D, Carbone M, Carrozzo M, et al. Br J Dermatol. 2006; 154:139.
  11. Cafaro A, Arduino PG, Massolini G, Romagnoli E, Broccoletti R. Lasers Med Sci. 2014 Jan;29(1):185-90.
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