Oral lichen planus
Introduction
Lichen planus (LP) is an inflammatory mucocutaneous disease that can involve the skin, hair, nails, and mucosal surfaces.1 The worldwide prevalence is estimated to be less than 5% without an obvious gender predilection. Mucosal sites of involvement include oral, genital, ocular, otic, esophageal, and, less commonly, bladder, nasal, laryngeal, and anal surfaces.2 Although the clinical range of LP manifestations is broad, the skin and oral cavity are the major sites of involvement. Oral lichen planus (OLP) is a mucosal variant of LP, which tends to be chronic, often requiring long-term treatment and clinical surveillance. Given the potential for multisite involvement, thorough physical examination of all cutaneous areas, mucosal sites, hair, and nails is warranted. Management is often multidisciplinary; dentists and dental specialists, dermatologists, gastroenterologists, gynecologists, otorhinolaryngologists, and ophthalmologists may all play a role in care depending on sites of involvement.2
Section snippets
Etiology and risk factors
The pathogenesis of OLP is not fully understood. It is considered to be a T-cell–mediated chronic inflammatory tissue reaction with both antigen-specific and nonspecific mechanisms hypothesized.3 Antigen-specific mechanisms include antigen presentation by basal keratinocytes, activation of CD4+ helper T cells, and cytokine release, resulting in a cytotoxic reaction against the epidermal basal cell layer. This supports the finding that the inflammatory infiltrate is primarily composed of
Cutaneous manifestations
On presentation, LP may affect one or multiple sites simultaneously. More than 5% of patients with LP have concurrent involvement of three or more sites.15 The oral cavity and skin remain the most commonly affected sites. Cutaneous LP is typically characterized by polygonal, violaceous, flat-topped, pruritic papules on the trunk or extremities with overlying reticular white striae known as Wickham striae. Although only 16% of patients with predominantly oral LP develop cutaneous lesions,15 two
Diagnosis
A diagnosis of OLP is made with a supporting patient history, physical examination, and histologic findings. The history should include review of systems, medical conditions, dental history, and medications. A thorough physical examination of all cutaneous and mucosal sites should be performed, specifically to identify less common sites of involvement as described earlier and avoid underdiagnosis of rare variants.
Although characteristic clinical features within the oral cavity may be sufficient
Treatment
The primary goal of treatment for OLP should be reduction of inflammation to permit healing, with the secondary goal of symptom alleviation, because no therapy is curative. Treatment should also be aimed at eliminating atrophic and ulcerative lesions and potentially decreasing the risk of malignant transformation.36 Patients with asymptomatic OLP such as limited white reticular lesions usually do not require treatment. Reticular OLP may be noticed incidentally during routine dental examination.
Prognosis and monitoring
The clinical course of OLP is often chronic, with waxing and waning severity. Patients are typically followed at least annually, which allows for assessment of disease activity and symptomology, as well as monitoring for early signs of malignancy, given a reported 1% lifetime risk of malignant transformation.[6], [18] In patients in whom lesions of OLP fail to respond to therapy or signs suggestive of oral cancer are present, biopsy should be obtained to rule out malignancy.
Conclusions
Although lichen planus can affect multiple cutaneous and mucosal surfaces, OLP continues to be a variant with a chronic course requiring long-term treatment and surveillance. Progress in research and awareness of OLP and other manifestations of the disease has led to growing recognition of clinical features and treatment options and emphasizes the importance of a multidisciplinary approach to therapy. This has led to more comprehensive patient care, particularly because it appears that mucosal
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