Oral lichen planus

Mr Anish Shah describes the diagnosis, management and treatment of this inflammatory oral disease.

Oral lichen planus: white patches form inside the mouth
Oral lichen planus: white patches form inside the mouth

Lichen planus is a mucocutaneous inflammatory disease of unknown aetiology. It is a common condition that mainly affects patients of middle age or older.1

The actual cause of lichen planus remains unclear. The predominantly T-lymphocyte infiltrate suggests an immunologically mediated cause. Drug-induced lichen planus is clinically indistinguishable from lichen planus.

Clinical features
Several types of oral lichen planus can be identified (see box).

The usual sites that are affected by oral lichen planus are the buccal mucosae and the tongue. The lips and gingivae can also be affected.

Lesions are usually symmetrical in nature. The simple reticular-type lesions are usually asymptomatic, unlike the erosive and atrophic types.

The majority of patients seeking treatment do so as a result of a referral from a healthcare professional.

Types of oral lichen planus

Reticular type - a lacy white pattern (striae) often bilateral. Annular patterns may also be identifiable.

Atrophic type - erythematous areas of mucosal thinning with or without striae.

Erosive type - irregularly shaped areas of epithelial destruction. Often these erosive areas are covered with a yellowish layer of fibrin. Striae may radiate from the margins.

Plaque type - these may be present in the early stages of oral lichen planus.

Management
It is recommended that all patients with suspected oral lichen planus are referred to the local oral surgical or medical department for probable biopsy. The majority of these patients have easily clinically identifiable oral lichen planus, however it is important to ensure that histological analysis confirms this.

It is important to ensure that patients are aware that lichen planus is not infectious. Treatment can include steroids in the form of topical applications or steroid-based mouthwashes - or in severe cases systemic steroid treatment.

Other treatment modalities involve dietary advice in so far as educating the patient which foods (spicy or acidic) may exacerbate soreness.

Some drugs may cause lichenoid reactions, including allopurinol, some ACE inhibitors, colloidal gold, some beta-blockers, some oral hypoglycaemics, some NSAIDs, methyldopa and antimalarials. Changing the drug can help.

Severe cases of oral lichen planus may be managed with medication such as azathioprine, tacrolimus and dapsone.

Lichen planus has been reported as having a 0.2-4 per cent chance of malignant change.2 It is important, therefore, to ensure that patients with other risk factors have any suspected lichen planus areas biopsied and other appropriate investigations undertaken.

  • Mr Shah is a specialist oral surgeon in London

References

1. EW Odell, RA Cawson. Cawson's Essentials of Oral Pathology and Oral Medicine. 8th Ed. Churchill Livingstone Elsevier, 2008.

2. Sigurgeirsson B, Lindelof B. Lichen planus and malignancy. An epidemiologic study of 2071 patients and a review of the literature. Arch Dermatol 1991; 127: 1684-8.

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