A 72-year-old woman is referred by her dentist for evaluation of intermittent burning and pain in her tongue and buccal mucosa induced by hot beverages and spicy foods. She takes medication for hypertension. Examination reveals discolored patches of the affected areas and scattered, hyperpigmented papules and macules on her wrists and ankles.
Can you diagnose this condition?
Submit your diagnosis to see full explanation.
Lichen planus (LP) is a chronic cutaneous inflammatory disease that affects the skin and mucous membranes. Oral cases, known as oral lichen planus (OLP), may affect up to 60% of individuals with LP and may infrequently occur without involvement of the skin.1 Patients typically present in the fourth decade of life with buccal, tongue, and/or gingival involvement. The disease may manifest with lesions that are lacy, reticular, papular, erosive, bullous, atrophic, or plaque-like. OLP is an autoimmune, T-cell mediated inflammatory disease that is induced by auto-cytotoxic CD8+ T cells.2 Degranulation of mast cells and activation of matrix metalloproteinase may play a role in pathogenesis.3 Some cases may be associated with hepatitis C infection. Medications and dental filling agents may also be associated with disease onset.4
High-potency topical steroids are considered first-line therapy. Refractory cases may respond to intralesional or systemic corticosteroids, topical calcineurin inhibitors, or cyclosporin, the latter of which is administered either orally or using a “swish-and-spit” technique.5 Malignant transformation is uncommon, occurring in approximately 1% of cases.6
Lauren Ax, MSPAS, PA-C, is a physician assistant on staff at the DermDox Center for Dermatology in Hazleton, Pennsylvania, and Stephen Schleicher, MD, is director of the DermDox Center for Dermatology, as well as an associate professor of medicine at Commonwealth Medical College and a clinical instructor of dermatology at Arcadia University and Kings College.
- Lavanya N, Jayanthi P, Rao UK, Ranganathan K. Oral lichen planus: An update on pathogenesis and treatment. J Oral Maxillofac Pathol. 2011;15(2):127-132.
- Eversole LR. Immunopathogenesis of oral lichen planus and recurrent aphthous stomatitis. Semin Cutan Med Surg. 1997;16:284–294
- Roopashree MR, Gondhalekar R, SHashikanth MC, George J, Thippeswamy SH, Shukla A. Pathogenesis of oral lichen planus- a review. J Oral Pathol Med.. 2010;39:729-734.
- Farhi D, Dupin N. Pathophysiology, etiologic factors, and clinical management of oral lichen planus, part I: facts and controversies. Clin Dermatol. 2010;28(1):100–108.
- Gupta A, Sardana K, Gautam RK. Looking beyond the cyclosporine “swish and spit” technique in a recalcitrant case of erosive lichen planus involving the tongue. Case Rep Dermatol. 2017;9(3):177-183.
- Alsarraf A, Mehta K, Khzam N. The gingival oral lichen planus: a periodontal-oral medicine approach.Case Rep De2019:4659134.