VANCOUVER – Gum involvement in oral lichen planus raises the risk of multisite or systemic disease, according to Dr. Roy Rogers, professor of dermatology at the Mayo Clinic in Rochester, Minn.
“When you see gingival involvement, this should stimulate you to look very carefully” for disease elsewhere, he said at the World Congress of Dermatology.
About 5% of oral lichen planus patients have involvement in three or more sites, and about 16% have cutaneous lesions, according to Dr. Rogers. Skin, eyes, ears, and nails are all potential targets, as is the esophagus. In fact, a complete oral exam may reveal erosive esophagitis to be an extension of oral lichen planus, which in some patients is painless and overlooked, he said.
Courtesy Dr. Damon McClain/Naval Hospital, Camp Lejeune, N.C.
A 34-year-old male with lichen planus.
Genital lesions are one of the most frequent extraoral manifestations of disease, and are easy to misdiagnose, especially in women. Dr. Rogers recalled a case of a woman who had several vulvovaginal surgeries before her lesions were recognized as lichen planus, and surgical trauma probably made her lesions worse. “A surgical approach is inappropriate until the disease is brought under control,” he said.
Lichen planus and its cutaneous manifestations are associated with hepatitis C, especially the Middle East, Southeast Asia, and the Mediterranean. Screening patients from those areas – as well as those with other risk factors – is appropriate.
Potentially 1% of lesions turn cancerous. Although the risk is low, “this requires regular follow-up either by you, or the patient’s dentist, or both” to monitor lesions, Dr. Rogers emphasized. “I encourage patients to see their dentist twice yearly and me at least yearly, if not more frequently, to renew their prescriptions and make sure everything is going well and not evolving into something else. If something’s not healing, a biopsy is indicated,” he said.
Good dental hygiene and care is a must for patients with oral lichen planus, because any inflammation in the mouth can exacerbate the condition. “Gingivitis, and certainly periodontal disease, should be controlled,” he added.
Fluorinated topical corticosteroids remain the standard of care, applied several times a day to lesions in the mouth or elsewhere to induce a remission, and then less often to maintain remission. Once the condition is under control, some patients need topical steroids only a few times a week.
When used in the mouth, topical corticosteroids can trigger secondary oral candidiasis, which patients might mistake for a flare. If their disease is under control, it almost always turns out to be thrush, said Dr. Rogers.
As an alternative to topical steroids, “I am an enthusiastic user of topical calcineurin inhibitors in oral lichen planus,” such as tacrolimus ointment, he said.
When an audience member asked about the risk of cancer from topical calcineurin inhibitors, Dr. Rogers responded, “it’s very, very low” because little is absorbed systemically. “It’s much more important to control the disease than allow it to continue” because the disease itself can lead to cancer, and treatment reduces the risk, he said.
Calcineurin inhibitors may, however, bump a precancerous lesion into a cancerous one, which is another reason for regular follow-up visits, and systemic treatment is called for in cases extensive disease, he added.
Dr. Rogers had no relevant disclosures.