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Oral Lichen Planus: Treatment Options

ABSTRACT

Estimates of the percentage of patients with cutaneous lichen planus (LP) who also have oral LP vary from somewhere between a third and a half 1-3, to as high as 70%4 and even higher when the cutaneous lesions are of long duration.4 Some 251–85%2-4 of patients present with only oral LP. Although about 65% of patients with cutaneous LP go into spontaneous remission after one year, such remissions have been estimated to occur in no more than 3% of patients with oral LP.5

Key Words: lichen planus, Topical corticosteroids, Acitretin

The underlying mechanism causing LP is thought to be a T-cell mediated immune response against foreign or autogenous antigens.6 At least two thirds of the patients with LP are between the ages of 30–60 and the disease is uncommon in the very young and in the elderly.7 Oral lichen planus (LP), if erosive or disseminated can be very resistant to treatment. Oral LP has many clinical presentations, with some lesions requiring no treatment and others needing management for decades.

Treatment rationale

Topical corticosteroids should be considered the treatment of choice unless the disease is very extensive.1,2 Systemic therapy is reserved for those with severe, refractory disease.3

Oral hygiene1-3 and corrective dentistry1-4 play a major role in the management of LP and consultation with a dentist or oral medicine specialist may be helpful.6

Oral hygiene1-3 and corrective dentistry1-4 play a major role in the management of LP and consultation with a dentist or oral medicine specialist may be helpful.6

Acitretin, combined with topical corticosteroid, can be effective, but should be reserved for patients who have not responded to corticosteroids alone. The retinoid should be used for several months and then tapered as patients improve.3 If acitretin is ineffective, other agents such as antimalarials, azathioprine or cyclosporine1 have been used.

Dental treatment

Indifferent oral hygiene leading to the formation of plaque and calculus exacerbates gingival LP, which may lead to severe gingivitis and periodontal disease.3 An optimal oral hygiene regimen should be instituted in all patients with oral LP, especially those with gingival involvement. Medical therapy should accompany oral hygiene measures.3 Certain oral clenching and sucking habits can make LP erosive or ulcerative, and habit splints have helped to modify these habits and reduce the inflammation.4 Oral trauma from ragged broken teeth and sharp prostheses are provocative.1 There is some evidence that the presence of gold and mercury amalgam fillings may provoke oral lichenoid reactions. Only a very small percentage of patients will respond to improved oral hygiene and corrective dentistry without further intervention.1,2

Lichen planus and hepatic disease

According to European reports hepatic disease does play a role in LP, its role seems to be less important in North America.1,2 Nevertheless, it is reasonable to obtain pertinent laboratory evidence on newly diagnosed patients, especially those with erosive disease.1,3

Practice points

  • 1% of patients with oral LP will develop oral squamous cell carcinoma.2
  • The relative importance of reversible causes of lichenoid eruptions, such as exposure to causative drugs (most commonly diuretics and non-steroidal anti-inflammatory agents), or hypersensitivity reactions to dental restorations has not been determined but a proper history should be obtained prior to instituting therapy.3
  • Secondary candidiasis should be suspected when acute exacerbations develop in patients being treated with chronic topical or systemic steroids or other forms of immunosuppression.3
  • There is increasing evidence that many women have concomitant lichen planus vulvar involvement, which either they are unaware of or decline to mention to their dermatologists. Female patients should be examined for vulvar involvement, or at least asked about symptoms.1 Penile lesions are common.
  • There are significant histologic differences between idiopathic lichen planus and a lichenoid drug eruption. It’s important to do a baseline biopsy to distinguish between these two entities and to have these biopsies read by a dermatopathologist.
  • Patients who consume alcoholic beverages which contain flakes of gold (Goldschlagger®, Gold Rush®, Gold Strike®) are at increased risk of developing generalized lichen planus. These drinks are more popular in Western Europe, especially with younger individuals, so in such patients inquiring about their patterns of alcohol consumption is prudent.1

Therapy for oral lichen planus5

First line

topical corticosteroids

Good safety & efficacy, low cost4 used on almost all patients.3,4

topical retinoids

Of value when combined with topical corticosteroids in conditions such as LP of the gingiva.3

Second line

acitretin

May be first choice in severe, resistant disease.8

oral corticosteroids and immunosuppressives

Use oral corticosteroids with caution for a short term. Azathioprine has also been used as a steroid-sparing agent. Cyclosporin does not appear to be better than topical corticosteroids4 and is very expensive.3,4

Investigational
(results need confirmation and these two new treatment approaches need further study)

Extracorporeal photochemotherapy

All seven patients in an open, prospective trial had complete remission of their chronic, erosive, oral LP, after 12 sessions over 1.5 months on average.9

Enoxaparin (a low molecular weight heparin)

Low doses given to 10 patients with intensly pruritic LP produced complete remission of non-oral skin lesions in eight patients and marked improvement in one; oral lesions improved in one out of four patients with oral LP.10

References

  1. Boyd AS. Personal communication March, 1997.
  2. Rogers RS. Personal communication May, 1997.
  3. Eisen D. Personal communications March, 1997 and June, 1998.
  4. Conklin RJ. Personal communication March, 1997 and June 1998.
  5. Chosidow O, Cribier B. Treatment of lichen planus: what is the right choice. Med & Surg Dermatol 1998; 5: 49–52
  6. Miles DA, Howard MM. Diagnosis and management of oral lichen planus. Dermatol Clin 1996; 14: 281–290.
  7. Arndt KA. Lichen planus. In: Fitzpatrick TB, Eisen AZ, Wolff K et al, eds. Dermatology in General Medicine. New York: McGraw-Hill, 1993.
  8. Maddin WS, Editor
  9. Becherest PA, Bussel A, Chosidow O et al. Extracorporeal photochemotherapy for chronic erosive lichen planus. Lancet 1998; 351: 805.
  10. Hodak E, Yosipovitch G, David M et al. J Am Acad Dermatol 1998; 38: 564–8.

In this issue:

  1. Oral Lichen Planus: Treatment Options
  2. Nail Psoriasis: Treatment Options
  3. Sunscreen Controversies
  4. Update on Drugs and Drug News - Number 6 1998