Can oral lichen planus lead to cancer

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Oral Lichen Planus With Malignant Transformation to Invasive Squamous Cell Carcinoma

To the Editor:

A 62-year-old woman with an extensive history of cutaneous and oral lichen planus (OLP) presented with gradual worsening of oral pain refractory to previously successful treatment regimens. The pains were described as sharp sensations originating in the right superior oral cavity, occurring almost constantly over the course of 2 months. On examination, the oral mucosa on the right side showed lacy, white, hyperkeratotic buccal lesions, as well as superficial erythematous erosion on the right upper alveolar ridge mucosa (Figure 1). On the left side, lacy, white, reticular patches were noted along the buccal mucosa. Gingival desquamation with superficial erosions were observed bilaterally, extending to the upper alveolar ridge in some locations. The skin examination revealed resolving, nonirritated, violaceous, flat-topped papules with a white-gray hue on the upper back and vulva.

Figure 1. Erosive oral lichen planus of the right maxillary alveolar ridge.

The rest of the physical examination was benign, including a lack of appreciable lymphadenopathy, a cranial nerve examination without focal deficit, and the presence of fluent unaffected speech. On review of systems, the patient denied fevers, chills, weight loss, or night sweats. She had no history of skin cancer or oropharyngeal cancer. Family history revealed that her father had nonmelanoma skin cancer of the head and neck. She denied heavy alcohol use as well as history of smoking or other oral tobacco products. Laboratory tests revealed a complete blood cell count and comprehensive metabolic panel that was within reference range. Due to the refractory nature of the pain, which was out of character for OLP, the patient was referred to an oral maxillofacial surgeon who extracted right maxillary teeth adjacent to the erosion to obtain an adequate specimen for surgical biopsy of the lesion itself. Histopathology confirmed the diagnosis of chronic erosive OLP with malignant transformation to localized squamous cell carcinoma (SCC) of the right maxilla.

While awaiting treatment, she began to develop unremitting headaches and painful shooting sensations beginning in the right superior oral mucosa, radiating to the ipsilateral naris, nasolabial folds, malar cheek, and temple region. This clinical picture was consistent with neuralgia occurring along the maxillary nerve. A subsequent computed tomography scan revealed local bony destruction of the primary tumor and likely perineural involvement (Figure 2), without notable nodal involvement or metastasis (stage III: T4aN0M0). An otolaryngologist performed a wide alveolar and maxillary excision with lymph node dissection. Surgical margins were deemed as negative and there was no evidence of nodal disease. She was later seen by the oncology and radiation oncology teams and received several courses of chemoradiotherapy.

Figure 2. Coronal (A) and axial (B) computed tomography demonstrated right maxillary bony destruction.

Seven months later, a new indurated ulcer was noted on the left lateral tongue. Biopsy revealed a new primary oral SCC (OSCC), which also was excised by an otolaryngologist. Recent computed tomography did not detect any recurrence or potential metastases, but the patient subsequently was lost to follow-up.

Lichen planus is an idiopathic inflammatory disease most commonly affecting the cutaneous skin as well as the oral mucosa, genital mucosa, nails, and scalp. Oral lichen planus is a relatively common manifestation, found in approximately 1% to 2% of individuals older than 15 years.1 Epidemiologic studies revealed that OLP is uncommon in children,2,3 it affects women more frequently than men (approximately 3:1 ratio),3 and its incidence peaks between 30 and 60 years of age.4 The literature on malignant transformation of OLP is varied and controversial, with some early investigations such as Krutchkoff et al5 concluding that the reported cases often fall short of supporting OLP as a premalignant source of OSCC due to insufficient evidence in claimed case reports supporting the diagnosis of OLP histopathologically, the occurrence of OSCC in sites where OLP lesions did not previously exist, and uncertainty regarding confounding factors such as carcinogen exposure.5 In contrast, a longitudinal cohort study reported malignant transformation in 2.4% of 
OLP cases (N=327), with a standardized incidence ratio of 17.7 (95% confidence interval, 8.8-35.3) when compared to a control group.6 Current literature has predominantly sided with the notion that OLP, especially the erosive variant, carries the risk for malignant potential6 as well as the World Health Organization’s classification of the disorder as precancerous.3

The pathophysiology of OLP and its potential for malignant transformation are unknown. It is believed that cell-mediated immunity, specifically CD8+ lymphocytes targeting stratum basale keratinocytes for apoptosis via the caspase cascade, plays a major role in the development of OLP, beginning with Langerhans cell recognition of an unknown basal cell antigen.3 Moreover, it is postulated that antigen expression is induced by certain drugs, infections, and contact allergens such as dental amalgams, explaining their known associations with OLP initiation and exacerbation. The etiology behind OLP developing into OSCC also is poorly understood and many different hypotheses have been suggested. Modified expression of p53, a 53-kd protein, in OLP patients has been demonstrated.6 Some investigators propose that a lack of the expected keratinocyte apoptotic response to the cell-mediated attack may be etiologic in cancerous transformation.3 Given their utility in treatment of OLP, there also has been apprehension over the potential for immunosuppressant medications leading to decreased expression of antitumor regulators and development of malignant cells, though it has not been substantiated by current literature.6 Finally, some cases of OSCC are believed to have been linked to N-nitrosobenzylmethylamine, a known carcinogen produced by colonized Candida albicans, which also may play a role in OLP treated with immunosuppressants.7

Erosive lichen planus

What is erosive lichen planus?

Erosive lichen planus is a chronic and painful condition affecting mucosal surfaces, mainly the mouth (oral lichen planus) and the genitals (vulval or penile lichen planus).

A severe variant or erosive lichen planus in women is known as the vulvovaginal gingival syndrome. Ulceration occurs in the mouth and gums as well as on the vulva and in the vagina. Peno-gingival syndrome is the equivalent condition in men.

Erosive lichen planus is sometimes associated with classical cutaneous lichen planus or other forms of mucosal lichen planus.

Who gets erosive lichen planus?

Erosive lichen planus most often affects people in their 40s to 70s. It is at least twice as common in women than in men.

What causes erosive lichen planus?

Erosive lichen planus is a destructive autoimmune disease of unknown cause involving T lymphocytes.

  • Occasionally, it is drug-induced and will resolve on withdrawal of the responsible drug.
  • Partial response to antifungal agents and antibiotics indicates an abnormal response to local microflora may be involved, especially Candida albicans.
  • Cytokine expression profiling has found increased levels of the interleukins, IL 17 and IL 23.

Clinical features of erosive lichen planus

Erosive lichen planus causes painful and persistent ulcers. These heal with scarring. It mainly affects adults, particularly women, and is rare in children.

Oral erosive lichen planus

In the mouth, erosions and ulcers may be the only signs (ulcerative stomatitis). They may occur inside the cheeks, on the sides of the tongue, on the gums, or inside the lips. Unlike short-lasting aphthous ulcers, erosive lichen planus lesions are larger and more irregular, and they may persist for weeks or longer. It can be very painful to eat, resulting in weight loss, nutritional deficiencies and depression.

Other forms of oral lichen planus may also occur, including white lacy streaks and inflammation and peeling of the gums (desquamative gingivitis).

Genital erosive lichen planus

In women, erosive lichen planus affects the labia minora (inner lips) and introitus (entrance to the vagina). The affected mucosa is bright red and raw. Erosive lichen planus can be very painful, stinging when passing urine and preventing sexual intercourse. It is one cause of vulvodynia (burning discomfort of the vulva). Erosive lichen planus may also result in very severe itch.

The clitoral hood may disappear, and the labia minora can shrink and stick to each other or to the labia majora (the outer lips). It can also scar, closing over the vagina.

Sometimes erosive lichen planus affects deep within the vagina where it causes inflammation and superficial ulceration (desquamative vaginitis). The surface cells in the vagina peel off and cause a mucky discharge. The eroded vagina may bleed easily on contact.

Erosive lichen planus in men affects the end of the penis (the glans), which becomes red, raw and tender.

Images of erosive lichen planus affecting the vulva

Other mucosal sites

Erosive lichen planus rarely affects the eyelids, external ear canal, oesophagus, larynx, bladder and anus.

What is the cause of erosive lichen planus?

The cause or causes of erosive lichen planus are unknown. It is considered an autoimmune disease, where immune cells called T-lymphocytes attack the epidermal cells of affected areas.

Erosive lichen planus is not due to infection or allergy.

Complications of erosive lichen planus

Infections

Patients with erosive lichen planus may develop infections particularly Candida albicans, herpes simplex, Staphylococcus aureus. Herpes infections are particularly painful and may cause vulval ulceration.

Squamous cell carcinoma

In about 1–3% of cases, longstanding erosive lichen planus can result in cancer (squamous cell carcinoma, SCC) of the mouth (oral cancer), vulva (vulval cancer) and penis (penile cancer). This should be suspected if there is an enlarging lump or an ulcer with thickened edges.

Some patients with erosive lichen planus have a particularly high risk of SCC.

  • Smokers
  • Patients that are immune suppressed due to disease or drugs
  • Patients infected with oncogenic types of human papillomavirus (HPV, see genital warts).

Scarring

Erosive lichen planus is a destructive disorder. Even when the inflammatory component has resolved, scarring may interfere with eating or sexual function.

How is erosive lichen planus diagnosed?

The diagnosis of erosive lichen planus is often made by the typical history and clinical appearance. A biopsy may be recommended to confirm the diagnosis and to look for cancer. Histopathological signs of a ‘lichenoid tissue reaction’ affecting the epidermis (the skin cell layer) are supportive.

However, the ulcerating nature of the disorder means that the epidermis may be missing so that lichenoid features may not be observed. The pathologist may describe a brisk inflammatory infiltrate in the mucosa, but this is non-specific.

Direct staining by immunofluorescent techniques may also be helpful.

Treatment of erosive lichen planus

The management of erosive lichen planus may be very challenging. As it is a chronic complaint, topical and systemic treatment may be required intermittently or continuously, long-term.

General measures

For oral disease, it is important to practice good oral hygiene and to have regular dental check-ups. Avoid foods that make the mouth sore.

The genitals should be gently washed using water alone or with a non-soap cleanser such as aqueous cream. A non-irritating emollient such as petrolatum may be applied as desired.

Ultrapotent topical steroids

Topical steroids generally applied daily for 4 to 6-week courses. They are the mainstay of therapy in most patients but maintenance treatment 1–3 times per week or more often may be necessary long-term.

  • In the mouth, topical steroids may be supplied as a paste, nasal spray (intended for rhinitis) or asthma-preventive puffer. These should be applied to the eroded areas two or three times daily.
  • For genital erosions, ultrapotent steroid ointment (eg clobetasol propionate) should be applied to the affected area as a thin smear once daily. Cream may be preferred, but is more likely to sting on application.
  • Hydrocortisone foam can be used inside the vagina or anus.

Calcineurin inhibitors

Calcineurin inhibitors such as pimecrolimus cream or tacrolimus ointment have proven very effective for some patients with erosive lichen planus. These are applied once or twice daily for several weeks. Treatment may be repeated as required.

Mouthwashes containing ciclosporin or tacrolimus have been found to help oral disease.

Systemic steroids

Systemic steroids such as prednisone may be prescribed for a few weeks or longer, usually at a dose of 0.5–1 mg/kg/day. Once the erosions have healed, the dose is tailed off. Longterm use of systemic steroids may have serious side effects. In many patients, calcium and vitamin D should also be prescribed to reduce the chance of corticosteroid-induced bone thinning.

Methotrexate

Methotrexate is taken in a dose of 10–20mg once weekly. Folic acid is often added to reduce the chance of potential adverse effects. This may be very effective for erosive lichen planus, with improvement or healing occurring within one to three months. It may be continued long-term if required. Blood count, liver function and procollagen levels should be monitored. Alcohol intake should be minimised. It must not be taken during pregnancy.

Other oral treatments

Other drugs that sometimes help include:

  • Antibiotics
  • Oral antifungal agents
  • Acitretin
  • Hydroxychloroquine
  • Azathioprine
  • Thalidomide

Surgery

Surgical release of vulval and vaginal adhesions and scarring from lichen planus may occasionally be performed to reduce urination difficulties and allow intercourse. Procedures may include:

  • Simple perineotomy (the division of adhesions)
  • Fenton procedure (an incision that is repaired transversely)
  • Perineoplasty (excision of involved tissue and vaginal mucosal advancement)

Lichen Planus

Lichen planus is a common disease that causes inflammation (swelling and irritation) on your skin or inside your mouth. On your skin, lichen planus causes a rash that is usually itchy. Inside your mouth, it may cause burning or soreness.

The cause of lichen planus is usually not known, although possible causes include:

  • Hepatitis C, a virus that attacks your liver

  • Certain medicines, including some drugs used to treat high blood pressure, diabetes, heart disease, and malaria

  • Reactions to metal fillings in your teeth

  • An autoimmune reaction, meaning the body’s own defense system, the immune system, attacks your mouth and skin cells by mistake

Symptoms

Symptoms of lichen planus depend on the part or parts of your body affected. Common symptoms include:

  • Skin: The most common symptoms are shiny red or purple bumps. These bumps are firm and may itch a little or a lot; you may have just a few or many of them. Fine white lines or scales may accompany the bumps. They can occur anywhere, but are most common on your wrists, arms, back, and ankles. Thick scaly patches may appear on your shins and ankles. Sometimes, bumps on your skin may appear in an area where your skin has been scratched or burned. Dark skin patches may replace skin bumps that fade. These patches usually fade away after many months.

  • Mouth: Lichen planus inside your mouth looks like lacy patches of tiny white dots. These patches may occur on the inside of your cheeks or on your tongue. They may not cause any other symptoms; in severe cases, redness and sores develop.

  • Nails: Lichen planus may appear on a few, or all, of your fingernails and toenails. Thinning, ridges, splitting, and nail loss are signs of the condition.

  • Scalp: Redness, irritation, and tiny bumps can form on your scalp. In some cases, hair may start to thin and patches of hair loss may occur.

  • Genitals: Lichen planus in your genitals can cause bright red, painful areas.

Who’s at risk?

About 1 in 100 people will get lichen planus at some time. It is not caused by an infection, and you can’t pass it on to others. Lichen planus usually affects men and women in middle age. Equal numbers of men and women get lichen planus of the skin, but women are twice as likely to get oral (inside the mouth) lichen planus. The disease is rare in people who are very young or very old.

Diagnosis

Your doctor or dentist may diagnose lichen planus, based on the changes on your skin or in your mouth. To make sure of the diagnosis, your doctor will perform a biopsy. He or she will remove mouth mucosa, or a small piece of skin, and send it to be examined it under a microscope.

Treatment

If your biopsy shows lichen planus and you have no symptoms, you probably do not need treatment. In most cases, lichen planus will go away within 2 years. If you have symptoms, such as severe itching or sores in your mouth or genital area, treatment can help. If you have lichen planus on your scalp, treatment is important to prevent permanent hair loss.

Lichen planus has no cure, but different treatments can help relieve your symptoms and speed healing. Possible treatments include:

  • Antihistamine medicine to relieve itching

  • Steroids on your skin or in your mouth to fight inflammation (You may also take steroids in pill form for severe cases)

  • A type of ultraviolet light treatment called PUVA

  • Retinoic acid, a medicine derived from vitamin A and usually used for acne

  • Tacrolimus and pimecrolimus, ointments used for eczema.

Complications

Some evidence suggests that oral lichen planus may be an early warning for oral cancer. Make sure you see your dentist for an oral exam at least twice a year.

When to call the doctor

If you have any symptoms of lichen planus, talk with your doctor. You may need to see a dermatologist for the most effective care.

How to manage or live with the condition

You can’t do much to prevent lichen planus, but once you have it, you can take steps to keep it from getting worse.

  • Avoid injuries to your skin.

  • Apply cool compresses instead of scratching.

  • Limit the stress in your life.

  • For oral lichen planus, stop smoking, avoid alcohol, maintain good oral hygiene, and avoid any foods that seem to irritate your mouth.

Lichen planus is not a dangerous disease, and it usually goes away on its own. However, in some people, it may come back.

Have you ever had your Plymouth, MN dentist complete a thorough head and neck exam and have them tell you that you have linea alba? Your first thought is “what is that?” You may have a chance to ask or there may be other things being discussed after the exam, and the question is forgotten. Linea alba is something dental providers see day and day out, so explaining what exactly it is to patients can sometimes be forgotten.

In dentistry, linea alba is defined as a white, horizontal line found on the inside of your cheek(s), level with the biting plane. What this tells your dentist is that you are likely clenching your teeth, resulting in the biting of your cheeks.

For the line itself, there is not much that can be done in the form of treatment for linea alba. However, solving the etiology of the problem is very important, for your teeth, your sleep and your muscles. For some, a nightguard or occlusal splint is needed. It may not stop you from clenching, but will prevent you from biting your cheeks, which in turn will eliminate the signs of linea alba. However, recent learning has told us half of all people who are given a splint, will have a reduction in their airway. A smaller airway makes it more difficult to get air in while sleeping with the splint in. In fact, the white line is very likely due to clenching the body does as a compensation. Clenching and grinding causes the muscles and jaw to move slightly, in order to open a compromised airway. Many people have failed at wearing splints because of a reduced airway when the jaw is propped open. Dentists blamed the problem on patient compliance. People may continue to clench or grind on their splint, sparing their teeth and reducing the white line inside their cheek, but the cause may not be solved. Ask your dentist to gather some sleep data on you with a recording device. Sleep diagnoses cannot be given, but the data can be interpreted to give more information on your airway, and if a splint is the right solution for you. Splints are custom made by dentists with the help of their labs, to specifically fit your needs. The type of splint that has been researched the most for obstructive sleep apnea is called a mandibular advancement device (MAD). Moving the jaw forward opens the airway while the splint is worn. Unfortunately, the improved airway is only while asleep, leaving the other hours of the day in question. Side effects of these types of splints include jaw pain and a change in your bite that may be significant and permanent. If your dentist doesn’t evaluate your airway, look for one who does on an airway health provider directory.

White patches in the mouth

What is a white patch in the mouth?

A white patch is an area of thickening in the lining of the mouth (mucosa) and has a white appearance (also called leukoplakia).

Why do people get white patches?

Your mouth (and tongue) are lined with a special type of skin (mucosa), which looks (mostly) pink because it is thinner than your other skin (eg on your arms and legs). Some changes to your mouth lining can change its colour to white:

  • It is common for people to have a line of white along the inside of their cheeks, this is where their teeth rub against the cheek (and is quite normal).

  • If you burn your mouth (eg after hot drinks or food) you can get white blisters, which usually peel off soon afterwards.

  • If you have been ill for a while or haven’t moved your tongue around much, you can get a furry white tongue. This is because the skin on the taste buds has not been rubbed off normally. You can usually gently rub/scrape this off with a toothbrush.

  • Mouth ulcers can be white because of thicker layers of skin cells forming that are trying to heal the injury.

  • If people have poorly fitting dentures they can get ulcers or sometimes white patches forming.

Dentists and doctors are most concerned about the white patches that can’t be rubbed or scraped away. These show areas of thicker mouth lining, which can be signs of mouth conditions.

Where are white patches found?

A white patch can be situated anywhere in the mouth.

How big are white patches?

A white patch can be of any size.

What causes a white patch?

White patches are almost always due to some form of irritation including infection:

  • Infection: eg fungal (candida)

  • Trauma and friction: eg poorly fitting dentures, cheek biting, sharp teeth or fillings (frictional keratosis)

  • Chemical irritation: eg aspirin burns, smoking (smoker’s keratosis);

Other types are due to a generalised condition of the skin and mucosa (see below) and some might not have an easily identifiable cause.

How are white patches diagnosed?

Often an experienced dentist or doctor can tell what kind of white patch you have by its appearance, position and by asking you questions about how long you have had it etc.

Sometimes they will wish to take a biopsy of a white patch to make sure it is not something that requires more involved treatment.

What will a biopsy involve?

A biopsy is a sample of mouth tissue (eg lip, cheek, gum, tongue) that enables us to look at it under a microscope. We will use local anaesthetic to numb the area and sew it up afterwards using dissolvable stitches (sutures).

The biopsy area might be a little sore for a couple of days afterwards and you should rinse your mouth with warm salted water for a week to keep the area clean.

What can be done to help white patches heal?

As described above, there are many causes of white patches. Your dentist (or doctor) might offer you the following advice:

  • Stop (or greatly reduce) smoking (smoker’s keratosis);

Or will offer you the following treatment to help it heal up (or prevent it forming):

  • Smoothing sharp edges on teeth (frictional keratosis);

  • Remaking or relining dentures;

  • Eradicating infection (such as fungal infections: candida);

I have a sore white patch, what can I do to make it more comfortable?

Occasionally, white patches can become sore. If this is the case, it is important to avoid anything that might make it worse, such as spicy or abrasive foods and alcohol.

If it remains a problem, your dentist or doctor can prescribe special mouthwashes or ointments.

Should I be worried about white patches?

Most white patches are a reaction to an irritation and are not a cause for concern. Very rarely, they can be an early sign of more serious mouth conditions (including mouth cancer). This is why it is important to seek advice from an experienced professional (your dentist or doctor) so they can help you remove possible reasons for them forming and follow up on any unusual ones.

I have a white patch that is being ‘watched’, how often will I need to return and what should I do between appointments?

Some people have white patches that we have some concerns about and are not sure if they will repair on their own (or after we have removed some of the possible causes of irritation).

We will explain that we are ‘watching’ the patch and would like you to return for a follow-up appointment (usually after 3-12 months).

It is important that you attend these appointments so we can check that the white patch has not changed.

Do heed any advice you are given about stopping smoking, and reducing a heavy alcohol intake, or cleaning the area.

Do keep an eye on the patch yourself and if you think that it has changed, or if it becomes painful or forms an ulcer or lump, please ring the dentist or doctor who is caring for you. Explain to them what you have noticed and they might decide to bring your appointment forwards. It is better that they take a look at it to stop you worrying about it.

What is leukoplakia?

Leukoplakia just means white patch in Greek. It is a term used for white patches that do not fit into any of the above categories, most of which have causes that can be avoided or treated.

If we are not sure of the cause and type of white patch we will often want to find out what is happening in the mouth or skin by taking a biopsy.

Depending on the biopsy result, we might recommend that the white patch is completely removed or carefully watched by an experienced professional to make sure that it doesn’t develop into anything more serious. These options will be discussed with you carefully.

Did you know?

What is lichen planus?

Lichen planus is a relatively common inflammatory disease that affects the skin and/or inside the mouth, resulting in distinctive skin and/or oral lesions. Lichen planus of the skin usually causes itching. There seems to be a relationship between the oral form and the skin form of lichen planus. Almost half of those with the oral version also have skin lesions. The onset may be gradual or quick, but the exact cause of the inflammation that leads to lichen planus is not yet fully understood. It is important to note that lichen planus itself is not an infectious disease. Therefore, this disease is not passed from one person to another by any means. Lichen planus is not a type of cancer.

Who gets lichen planus?

Lichen planus affects around one percent of the general population. Both men and women can get lichen planus. Skin lichen planus affects men and women equally, but oral lichen planus affects women twice as often as men. Although it may occur at any age, it usually affects middle-aged adults. It is uncommon in the very young and elderly. This disease can affect any individual all over the world, regardless of the race, skin color and culture.

What are the signs and symptoms of lichen planus?

Lichen planus of the skin appears as small, flat-topped, red-to-purple bumps with round or irregular shape. You may have just a few small bumps or you may have many. If you take a closer look, you might see white scales or flakes on them. Some may have wispy, gray-to-white streaks called Wickham’s Striae. Lichen planus causes itching with an intensity that varies in different people from mild to severe. Sometimes the bumps don’t itch, but typically they do. Lichen planus can appear on any area of the skin. The most common areas are the inner wrists, the forearms and the ankles. It may also affect the scalp?or the nails. On the scalp, it may cause redness, irritation, and, in some cases, hair loss. Sometimes this disease affects the areas of skin where you had a trauma, such as a superficial scratch, cut, or burn. Lichen planus of the nails can cause brittle or split nails, and the affected nails may have ridges running lengthwise. In the mouth, lichen planus looks like lacy white patches on the inside of the cheeks or on the tongue. Oral lesions do not usually cause symptoms, though severe outbreaks may cause painful sores and ulcers that make it hard to eat and drink. Lichen planus can affect the female genitals, including the vagina. In the vulva or vagina, it may appear as bright red patches or sores. Such condition can be confused with sexually transmitted diseases, although lichen planus is neither sexually transmitted nor contagious as mentioned above. Genital lichen planus does not usually cause symptoms, but open sores may be quite tender.

What cause lichen planus?

In most cases, the cause of lichen planus can’t be found. It is not caused by stress, but sometimes emotional stress makes it worse. This disorder has been known to occur after contact with certain chemicals, such as those used to develop color photographs. Some cases of lichen planus may be linked to chronic hepatitis C virus infection. This virus can cause serious liver diseases, such as liver cirrhosis and liver cancer. Your doctor may need to order a blood test to check for hepatitis C virus. In some people, certain drugs cause lichen planus. These drugs include medications for high blood pressure, heart disease, diabetes, arthritis and malaria, antibiotics, non-steroidal anti-inflammatory pain killers, etc. It is important to tell your doctor all the medicines you are taking. The rashes will go away after the offending drug is stopped. People who have lichen planus in the mouth may be allergic to certain products used during dental procedures, such as amalgam fillings. Patch testing may be used to specify the allergy; removal of dental material is recommended and may result in cure.

How is lichen planus diagnosed?

The diagnosis of lichen planus is often made by a dermatologist, oral surgeon or dentist on the basis of the typical clinical appearance. A skin biopsy may be needed to confirm the diagnosis. In case of oral lichen planus, your physician may have to make sure that the lesions are not caused by yeast, and a biopsy is often recommended to confirm or make the diagnosis and to rule out other oral diseases including cancer (see below). For a biopsy, a small bit of skin or mucosa is taken from the lesion. It is sent to a laboratory to see if it is actually lichen planus by microscope.

How is lichen planus treated?

Most of the time, the bumps go away without any treatment after about a year. However, treatment can make your skin look better. The goal of treatment is to reduce your symptoms and speed healing of the skin lesions. If symptoms are mild, no treatment may be needed. There is no known cure for skin lichen planus, but treatment is often effective in relieving itching and improving the appearance of the rash until it goes away. Lichen planus of the scalp must be treated right away, or the hair of the affected area may never grow back. Since every case of lichen planus is different, no one treatment does the job. Topical corticosteroids are very useful. You can use a corticosteroid ointment or cream that you apply directly to the bumps. Corticosteroids may be injected directly into a lesion. In the mouth, steroid pastes or inhalant powders may be easier to apply to affected sites. Hydrocortisone foam can be used inside the vagina. Antihistamines may be prescribed to relieve itching. Extensive cases may require the use of oral corticosteroid for a few weeks or longer. This usually shortens the duration of the outbreak, but may have serious side effects. Ultraviolet light therapy (also called PUVA) may be beneficial in some cases. The so-called immune modulating drugs, tacrolimus ointment and pimecrolimus cream, may be useful for oral and genital lichen planus. Other treatment options include topical or oral retinoid (a form of vitamin A), long term antibiotics, oral antifungal agents, phototherapy, methotrexate, hydroxychloroquine, etc.

What is the long-term outlook for lichen planus?

In general, lichen planus is not a harmful or fatal disease. It usually goes away by itself in time, but can persist for a long time, running into years, and this varies from patient to patient. The presence of skin lesions is not constant and may wax and wane over time. Oral lesions tend to last longer than those of the skin. Furthermore, even after going away completely, lichen planus may recur. As it heals, lichen planus often leaves a dark brown discoloration of the skin. Like the bumps themselves, these stains may eventually fade with time without treatment. When oral mucosa is affected by lichen planus, there is a slightly increased risk of developing oral cancer. If oral lichen planus is present, you should avoid the use of alcohol and tobacco products, which also increase the risk. Regular visits to the dermatologist or dentist — at least twice a year — for an oral cancer screening is recommended.

More information

Did you know lichen planus affects not only skin but also oral mucosa?

Lichen planus is a long standing, itchy skin disease of unknown cause. It frequently affects the inside of the mouth as well. If it occurs in the mouth, the membranes appear gray and lacy. In addition, it can affect other parts of the body, such as the nails, scalp, vulva, vagina and penis.

Did you know lichin planus is not a harmful disease?

Although lichen planus is a disease of uncertain cause and is difficult to be cured by treatment, this skin disease itself is neither life threatening like cancer nor infectious. Therefore, lichen planus is very unlikely to affect your general health and cannot be passed on. Most cases of lichen planus disappear even without treatment in the long course of time.

Did you know some cases of lichen planus may be reaction to particular medicine?

In some people, certain drugs may cause lichen planus. These include widely-prescribed drugs such as medications for high blood pressure. Thus, it is important to tell your doctor all the medicines you are taking.

Did you know some cases of lichen planus may be linked to hepatitis C virus infection?

Lichen planus has been reported as a complication of chronic hepatitis C virus infection. This virus can cause serious liver disease. Your doctor may need to order a blood test to check for hepatitis C virus.

Hello!

How strange you should write now as I’ve actually had a patch of OLP come up on my gum after so long of it being absolutely fine. I am 100% sure of the cause though and so hopefully this can help you.

Although some people’s Lichen Planus appears to develop with no cause and nothing they do seems to be able to make it go away, I’ve found that with me, like with so many others, there is a definite cause. I felt mine was stress and diet related and the more I researched, the more I discovered the links between LP (or in my case Oral LP) and the immune system and the effects diet and stress have on your immune system. Lack of sleep, lack of exercise (particularly exercise outdoors in the fresh air and sunlight), diet, stress, anxiety, medications and diet all effect our immune system which in turn affects our health. In fact, I believe that our gut is 80% of our immune system AND stress believe it or not actually affects the balance of our gut and immune system due to the biological chemicals our body creates when under stress. So getting all this balanced can be quite tricky as it’s a lot to get right in so many areas.

I started with my diet. I bought a NutriBullet and every day I make a smoothie with strawberries, blueberries, banana, avocado, spinach and organic coconut milk and water. Oh and organic Flax seed. It really is an important way to start the day. Eat natural yoghurt too and look for yoghurts that list the most cultures in the description/ingredients. Limit meat and also processed foods. And limit alcohol. This doesn’t mean you have to give it up. Just make sure that you choose wisely when you want to eat unhealthy foods or drink alcohol. Just like if you were trying to stick to a weight loss diet and you let yourself cheat for a birthday party but you knew that the next day you needed to be good again. Once you’re starting to see positive differences and you maintain this lifestyle for a few months with no LP symptoms, you can then give in a little more often to things but just really pay attention to your body and any signs of the LP coming back. And make sure you are sensible with how you “give in” to cravings such as, “OK, I’ve eaten great all week and I really want some cake so I’ll have a sensible serving of it and then make sure I don’t snowball into eating everything else that’s bad.”

Walking has helped me lots. Just out in the fresh air and natural light, getting my heart rate up a little has really made a difference. If you can walk every day, do. Summer is a great time to start a walk in the evenings. I had a friend go with me and we walked all year round, even when it rained, and we chatted and it was just really nice.

Get to bed at a decent hour and make sure you get your 8 hours at least each and every night. So much has come out again recently about how lack of sleep has such a detrimental affect on our body and brains. And you only need to think about when you’re not well and go to bed and you nearly always feel better in the morning as sleep helps you heal.

Meditation! I NEVER thought this would work. Not until I watched an excellent show where they took celebrities to Sardinia to see if they could make them “younger” through natural ways. Sardinia is one of the 5 (I think it’s 5) Blue Zones in the world where all disease rates are lower and life expectancy is longer on average than anywhere else. Scientists study these areas and if you google Blue Zones you should find a great web site with that in the title. It’s a great web site with lots of healthy living suggestions based on real research and scientific findings. Anyway, meditation was addressed on the show I watched and unbeknownst to me, there was actually tremendous world wide research about the overwhelming health benefits of meditation. I researched myself and decided to get an app called Calm. It’s a fantastic app and has received App of the Year awards. You pay a subscription but if you get it and you use it then it will benefit you tremendously. Just 10 minutes a day is all you need. I meditate before bed. I deal with stress so much better now. Meditating doesn’t stop stress but it changes how your body deals with it and actually rewires your brain to cope better which in turn doesn’t release as much of the harmful stress chemicals which in turn then doesn’t fuel your LP and any other diseases such as cancer. Meditation can’t stop these things of course, but it can make your body stronger against them and help fight them off for longer. It’s a very easy app and walks you through everything. There’s so much on the app. If you can get it, please do as you won’t regret it but do keep up with meditating daily as much as you can.

Limit sugar too by the way and any artificial ingredients.

I really hope this has helped! It took me 3 months of this (and a good multivitamin and organic turmeric capsules (I take one a day but 2-3 if ever I notice symptoms returning).

At the moment I have OLP symptoms. I had a very badly trapped nerve and I had to take a muscle relaxant and ibroprofen. The relaxant made me feel nauseous and induced feelings of anxiety when I stopped taking it (even though I took half the dose as I try to be very careful with medications and I don’t like taking them). I believe it was as a result of this medication that I now have a small flare up. So as soon as that happens, I make sure I drink lots of water, have no sugar or artificial ingredients, I get to bed earlier, I meditate more if I can to help with the stress/anxiety, I take 2-3 turmeric capsules for a few days (3 today as my gum is quite red so I need to stop it in it’s tracks. I would take just two for a few days if I get an uncomfortable patch of gum that isn’t yet angry looking. Turmeric is good but in moderation. In fact, it’s very, very good for inflammation in moderation. I even break from using it if I am doing OK). I will also make sure I don’t miss out on walking and will eat really well.

Please let me know if I can help in any other way! For the majority of people, LP really does seem controllable if you’re willing to make changes. I feel better than ever for the changes so it’s worth making them

Oral Lichen Planus

Lichen planus is a disease that can affect the skin and any lining mucosa. This could be the oral, esophageal, vaginal mucosa as well as the skin. Often, it is found only in the oral cavity. Overall, lichen planus affects approximately 2 percent of the population. Although the disorder may occur in all age groups, women over the age 50 years are most commonly affected.

Cause
The cause of lichen planus is not completely understood, but genetics and immunity may be involved. Findings suggest that the body is reacting to an antigen (i. e. an allergic type reaction) within the surface of the skin or mucosa. Some authorities think that lichen planus is an autoimmune disorder in which the skin cells lining the mouth are attacked by the white blood cells, but more research is needed. Others classify lichen planus as a cell-mediated immune response and believe that since a specific antigen has not been identified, it is premature to classify the disorder as autoimmune.

Appearance in the Mouth
Lichen planus can appear in the mouth in several different patterns. The reticular pattern (see right) is commonly found on the cheeks as lacy web-like, white threads that are slightly raised. These lines are sometimes referred to as Wickham’s Striae. The name lichen comes from a plant that is often seen growing on rocks with its mossy, web-like appearance.

The erosive (atrophic) pattern can affect any mucosal surface, including the cheeks, tongue, and gums (see left). This form often appears bright red due to the loss of the top layer of the mucosa in the affected area. In most instances, individuals with erosive lichen planus are uncomfortable when eating and drinking, particularly with extremes of temperature, acidic, coarse, or spicy foods.

In severe cases, ulceration can develop (see below Left). Individuals affected by ulcerations may experience pain even when not eating or drinking. A less common form of lichen planus is the plaquelike lichen planus, which appears as a dense thickening of the mucosal tissue (see below Right).

Lichenoid reactions are instances of mucosal disease that resemble lichen planus both clinically and microscopically, but are due to an allergic response (see Right). The list of potential offending agents is extensive and includes medications, oral hygiene products and occasionally, metallic filling materials placed by your dentist. Identifying the underlying cause of a lichenoid reaction is often challenging, but when successful leads to lesion resolution.

The severity and subsequent disability caused by lichen planus varies from inconsequential to severe. Skin lesions are typically present as a purple to brown in color, raised rash that can be very itchy (see Left). In addition to the oral mucosa, other mucosal surfaces such as the eyes, esophagus, and genitalia may be affected.

QUESTIONS AND ANSWERS ABOUT ORAL LICHEN PLANUS

Q: How do I know if I have oral lichen planus?
A: The diagnosis must be obtained from a qualified health care professional. Usually, a biopsy is advisable to establish the diagnosis and rule out other diseases.

Q: I have oral lichen planus and my mouth hurts each time I brush my teeth. How do I avoid this?
A: Often with oral lichen planus, it is necessary to use a mild tooth paste with a minimum of flavoring and other ingredients. A soft tooth brush is essential.

Q: What treatment is necessary for oral lichen planus?
A: Often the reticular form of oral lichen planus does not require any treatment, except periodic observation by a health care professional. The erosive and ulcerative forms can usually be controlled with the use of topical corticosteroids. In some cases, systemic steriods or other medicines may be prescribed by your doctor.

Q: Does oral lichen planus go away with treatment?
A: Oral lichen planus is a chronic disease that can be controlled but not eliminated. A goal of therapy is to convert bothersome erosive or ulcerative oral lichen planus to the asymptomatic reticular form. Individuals with oral lichen planus often require some form of maintenance therapy to keep their disease under control. Oral lichen planus can be controlled but often will exhibit disease flare-ups requiring additional. Finally, following a healthy lifestyle consisting of a well-balanced diet, exercise and stress reduction is also beneficial.

Q: Is oral lichen planus contagious?
A: No. Your partner or family member will not be infected by oral lichen planus and you did not catch it from anyone.

Q: Can oral lichen planus lead to oral cancer?
A: This association remains controversial, but there are reported cases of this occurring. This concern reinforces the essential need to obtain an accurate diagnosis, typically with a biopsy. All patients with oral lichen planus should have a periodic evaluation to asses the efficacy of therapy and to monitor for suspicious changes. If your oral lichen planus does not respond to treatment or if you should notice a significant change, you should contact your heath care provider for further evaluation.

Other Sources of Information on Oral Lichen Planus

  • International Oral Lichen Planus Support Group
  • Academy of Nutrition and Dietetics
  • American Academy of Dermatology
  • American Dental Association (General Oral Health Information)
  • American Academy of General Dentistry
  • National Organization of Rare Diseases (disease related information)

Prepared by N. Burkhart and the AAOM Web Writing Group
Updated September 2013

Japanese Translation – 日本語訳
Spanish Translation – Traducción Español

The information contained in this monograph is for educational purposes only. This information is not a substitute for professional medical advice, diagnosis, or treatment. If you have or suspect you may have a health concern, consult your professional health care provider. Reliance on any information provided in this monograph is solely at your own risk.

Mouth Problems

Step 3

Possible Causes

  • See Mouth Problems in Infants and Children
  • This lesion may be a precancerous LEUKOPLAKIA, more common in those who use tobacco.

    Self Care

    See your doctor. Stop smoking or using other tobacco products to help prevent oral cancers. See your dentist if sharp or rough teeth or dental work are causing irritation.

  • This may be SQUAMOUS CELL SKIN CANCER.

    See your doctor. When there is any change in the color, size, texture or appearance of the skin, or if there is pain, itching or bleeding from a lesion, lump or mole, see your doctor.

  • This may be a MUCOCELE, a harmless cyst that may be caused by sucking mouth tissue between the teeth.

    These cysts usually go away on their own. To avoid infection, only a doctor should open these cysts.

  • This may be a blockage in a salivary duct, possibly caused by a SALIVARY DUCT STONE.

    See your doctor.

  • These may be CANKER SORES. They may be caused by viral infections.

    Canker sores usually heal on their own. To relieve discomfort, rinse with salt water or diluted hydrogen peroxide, or apply an over-the-counter oral gel. You may also use an analgesic such as acetaminophen or ibuprofen to relieve pain. See your doctor if your symptoms don’t improve.

  • This may be a COLD SORE, caused by a type of HERPES VIRUS.

    Cold sores usually go away on their own. Analgesics, such as acetaminophen, and cold sore ointments can help relieve the discomfort.

  • This may be an ALLERGIC REACTION to a medicine or another ALLERGEN.

    URGENT
    See your doctor or go to the nearest emergency room right away if you have any trouble breathing. An antihistamine may help relieve other allergy symptoms.

  • MISFITTING DENTURES can cause mouth pain.

    See your dentist.

  • You may have GUM DISEASE such as GINGIVITIS or PERIODONTITIS, or a CAVITY, usually caused by poor ORAL HYGIENE.

    See your dentist. Good oral hygiene, such as regular brushing, flossing and dental checkups, and eating a healthy diet can help prevent gum diseases.

  • Do you have small, painful bumps on your tongue?

    The inflammation and bump will usually go away on its own. Avoid hot, spicy and acidic foods. Use an analgesic, such acetaminophen or ibuprofen, to relieve pain.

  • This may be CANDIDIASIS (ORAL THRUSH) caused by a fungus growing out of control.

    This condition usually goes away on its own. Eat unsweetened yogurt with live cultures to restore the natural balance of bacteria in your body. Gargle with salt water or use analgesics, such as acetaminophen, to relieve discomfort. If your symptoms get worse or don’t improve, see your doctor. He or she may prescribe an antifungal medicine.

  • You may have ORAL LICHEN PLANUS, an inflammatory condition that may have many causes.

    This condition may go away without treatment. Practice good oral hygiene, such as regular brushing and flossing, don’t eat foods that irritate your mouth, limit alcohol consumption, and stop smoking. See your doctor if your symptoms get worse or don’t improve.

  • You may have BURNING MOUTH SYNDROME (BMS).

    See your doctor. Treatment often depends on underlying causes. Stop smoking or using other tobacco products. Their use may be the cause or may make the problem worse.

  • These tender sores may result from a vitamin deficiency or from chapped lips.

    Use a soothing ointment on these cracked areas. Take riboflavin and/or a multivitamin if you think your diet isn’t adequate. See your doctor if your symptoms don’t improve.

  • See your doctor if you have a mouth or lip sore that doesn’t heal. This may be a sign of oral cancer. For more information, please talk to your doctor. If you think the problem is serious, call your doctor right away.

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