Derm Dx: Painful Lesions in the Mouth - Clinical Advisor

Derm Dx: Painful Lesions in the Mouth

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A 25-year-old man presents for evaluation of painful lesions in his mouth that have been present for 2 months. The patient reports that the lesions are often bothersome when speaking or eating. He is currently not taking any medication (nor at the time of lesion onset) and does not have a history of systemic disease, including hepatitis. Clinical examination reveals denudation and crusting of his lips and desquamation and erythema of the upper and lower gingivae. Intraoral examination reveals diffuse erythema with multiple eroded lesions predominately situated on the posterior buccal mucosa. The palate and floor of his mouth are also affected. Examination of his skin is unremarkable.

Oral lichen planus (OLP) is a chronic inflammatory disease that affects the mucous membrane. The most common subtype is the reticular variant, which appears as white patches on the inside of the cheek and is often asymptomatic.1 Erosive OLP, however,...

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Oral lichen planus (OLP) is a chronic inflammatory disease that affects the mucous membrane. The most common subtype is the reticular variant, which appears as white patches on the inside of the cheek and is often asymptomatic.1 Erosive OLP, however, is painful and results in varying degrees of discomfort.

The condition presents with erythema and ulceration. Pseudomembrane formation and reticular keratotic striae surrounding erosive lesions may also be identified.2 The most common location is the buccal mucosa, followed by the lingual, gingival, and labial mucosa.

Diagnosis of erosive OLP is made by clinical and histologic examinations.3  In this case, biopsy of the lesions revealed degeneration of the basal layer of the epithelium and a subepithelial lymphocytic infiltrate. Direct immunofluorescence was negative.

First-line treatment for OLP is topical steroids preferably in either gel or ointment form. Intralesional or systemic steroids may be used for refractory cases. Retinoids and calcineurin inhibitors may also prove effective as well as oral and topically suspended cyclosporine.4,5 

Erosive OLP can be associated with chronic hepatitis C virus.6 A serious complication of erosive OLP is a malignant transformation; this risk is increased by smoking, alcohol consumption, and hepatitis C virus infection.6

Faten Rabhi, MD, Kahena Jaber, MD, Mohamed Raouf Dhaou, MD, and Nejib Doss, MD, are from the Department of Dermatology, Military Hospital of Tunis, Tunisia. Stephen Schleicher, MD, is director of the DermDox Center for Dermatology in Pennsylvania, as well as an associate professor of medicine at Commonwealth Medical College and a clinical instructor of dermatology at Arcadia University and Kings College.                                                        

References

1. Gorouhi F, Davari P, Fazel N. Cutaneous and mucosal lichen planus: a comprehensive review of clinical subtypes, risk factors, diagnosis, and prognosis. Sci World J. 2014;2014:742826.

2. Alrashdan MS, Cirillo N, McCullough M. Oral lichen planus: a literature review and update. Arch Dermatol Res. 2016;308(8):539-551.

3. Mutafchieva MZ, Draganova-Filipova MN, Zagorchev PI, Tomov GT. Oral lichen planus – known and unknown: a review. Folia Med (Plovdiv). 2018;60(4):528-535.

4. Ioannides D, Vakirlis E, Kemeny L, et al. European S1 guidelines on the management of lichen planus: a cooperation of the European Dermatology Forum with the European Academy of Dermatology and Venereology.  J Eur Acad Dermatol Venereol. 2020;34(7):1403-1414.

5. 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.

6. González-Moles MÁ, Ruiz-Ávila I, González-Ruiz L, Ayén Á, Gil-Montoya JA, Ramos-García P. Malignant transformation risk of oral lichen planus: a systematic review and comprehensive meta-analysis. Oral Oncol. 2019;96:121-130.

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