Oral Lichen Planus
Tuesday, September 23, 2008
Oral lichen planus (OLP) is as common as psoriasis and affects
approximately 1-2% of the population.1 The disease
develops in women more than twice as often as in men and most
commonly occurs in the fifth to sixth decade of life; although, the
disease can sometimes affect children.2, 3 In
patients with OLP, cutaneous disease develops in approximately 15%
and vulvar and/or vaginal involvement in 25%. However, scalp, nail,
esophageal and ocular involvement are
uncommon.4 cutaneous lesions of lichen planus (LP)
are self-limiting and pruritic,5 whereas oral
lesions are chronic, rarely undergo spontaneous remission,
potentially premalignant, and are often a source of morbidity and
difficult to palliate.
OLP may manifest in one of three clinical forms: 1) reticular,
including raised hyperkeratotic papules and plaques; 2)
erythematosus, including atrophic lesions; and 3) erosive,
including ulcerated and bullous lesions. Reticular lesions, the
most recognized form of OLP, often occur as isolated lesions and
may be the only clinical manifestation of the disease. Erythematous
lesions are accompanied by reticular lesions and erosive lesions
are accompanied by reticular and erythematous lesions in almost all
cases. This feature helps clinically differentiate OLP from other
diseases such as pemphigus and pemphigoid, which are characterized
by isolated areas of erythema and/or erosions. Erythematous and
erosive lesions result in varying degrees of pain as well as
burning, swelling, irritation, and bleeding with brushing.
The diagnosis of OLP can be made from the clinical features if
they are sufficiently characteristic, particularly if typical skin
lesions are also present, but biopsy is recommended to confirm the
OLP develops most frequently on the posterior buccal mucosa
followed by the tongue, gingiva, labial mucosa, and vermilion of
the lower lip. Lesions on the palate, floor of the mouth, and upper
lip are uncommonly observed. Approximately 10% of patients with OLP
have the disease confined to the gingiva and present as raised
white lacy lesions or more commonly as desquamative gingivitis,
typically with atrophic and erosive lesions. Direct
immunofluorescence is an effective method of excluding other causes
of desquamative gingivitis that share similar clinical features
with OLP, including pemphigus, pemphigoid, linear IgA disease and
foreign body gingivitis.6
Oral lichenoid reactions, eruptions in the oral cavity that have
an identifiable etiology and that clinically and histologically
resemble OLP, are well recognized. An allergy or toxic reaction
should be suspected when OLP lesions are confined to areas of the
oral mucosa in close contact with amalgam restorations, especially
fillings that are worn and cracked. When identified, such lesions
show considerable improvement after replacement of the filling.
Although uncommon, drug-induced oral lichenoid reactions are
reversible upon withdrawal of the implicated drug. Therefore, a
thorough medication history, with emphasis on non-steroidal
anti-inflammatory drugs and angiotensin-converting enzyme
inhibitors, is warranted. Many drugs implicated in cutaneous
lichenoid reactions have not been associated with oral lesions.
An association between hepatitis C virus (HCV) infection and OLP
has been investigated, but studies have been inconsistent. While
many reports have demonstrated a significant association of the two
diseases in Southern Europe and in Asia, studies from Northern
Europe and North America failed to demonstrate any
link.7 These conflicting results may be related to
genetic factors however, with further prospective studies
The development of squamous cell carcinoma is controversial but
is the most feared complication of OLP. Studies of the malignant
potential of OLP have been fraught with inconsistencies in the
diagnostic criteria of OLP and the criteria adopted to identify a
true case of malignant transformation. The reported frequency of
malignant transformation varies between 0.4% to over 5% over
periods of observation from 0.5 to over 20 years, with almost all
carcinomas developing in patients with atrophic and/or erosive
lesions.8 Given the uncertainty of the premalignant
nature of OLP and the fact that early detection of oral cancer
results in improved survival, it seems prudent to monitor all
patients with OLP carefully and long term.
Topical corticosteroids are the mainstay of treatment of OLP
with 65% to 100% responding at least
partially.9 Generally, higher potency preparations
appear to be most effective, achieving a rapid response; one should
lower the strength of the steroid as soon as erosions heal and
erythematous lesions become asymptomatic. Once the disease becomes
inactive with only white reticular lesions present, therapy may be
For intractable erosive OLP lesions, intralesional triamcinolone
(10-20 mg/ml) injections can be highly effective and repeated every
Potent topical immunosuppressants such as cyclosporine,
tacrolimus, and pimecrolimus are beneficial for
OLP.10-12 The high cost of cyclosporine precludes
its routine use although utilizing a small quantity of drug reduces
the cost. In small controlled studies, both pimecrolimus and
tacrolimus reduced the symptoms and signs of OLP. Burning was the
most common side effect of each. Tacrolimus may be at least as
equally effective or more effective than potent topical steroids.
However, relapses of OLP after cessation of therapy is expected
with calcineurin inhibitors. When I use one of these agents, I do
so in conjunction with a topical steroid using both twice daily.
Given the Food and Drugs Administration (FDA) warning about
calcineurin inhibitors and the potential association with an
increased risk of cancer, the long-term use of these drugs for this
chronic disease may be limited.
A number of systemic immunosuppressive agents have been
anecdotally reported to be beneficial in the treatment of
OLP.13 Based upon my personal experience of
treating over two thousand patients, I have found that methotrexate
(12.5-20 mg/week), azathioprine (100-150 mg/day), mycophenolate
mofetil (1-2 g/day), and hydroxychloroquine (400 mg/day) are the
most useful systemic agents. We and others have also been using
thalidomide and tumor necrosis factor (TNF)-alpha inhibitors for
refractory cases. Although none of these agents provide long-term
remission, significant clinical benefits are achieved and
maintained with long term administration. It is unclear whether
reducing inflammation by aggressive therapy influences the
malignant transformation of the disease.
Finally, it is important to minimize or eliminate exacerbating
factors such as heat and irritation from tobacco products, friction
from sharp cusps, rough dental restorations and poorly fitting
dental prostheses, and oral habits including lip and cheek chewing.
OLP lesions will then either revert to the less severe forms of the
disease or resolve completely.
- Scully C, Beyli M, Ferreiro MC, et al. Update on
oral lichen planus; etiopathogenesis and management. Crit
Rev Oral Biol Med. 1998;9:86-122.
- Eisen D. The clinical features, malignant potential, and
systemic associations of oral lichen planus: a study of 723
patients. J Am Acad
- Nanda A, Al-Ajmi HS, Al-Sabah H, et al. Childhood
lichen planus: a report of 23 cases.Pediatr
- Eisen D. The evaluation of cutaneous, genital, scalp, nail,
esophageal, and ocular involvement in patients with oral lichen
planus. Oral Surg Oral Med Oral Pathol Oral Radiol
- Boyd As, Neldner KH. Lichen planus. J Am Acad
- Helander, SD, Rogers RS 3rd. The sensitivity and specificity of
direct immunofluorescence testing in disorders of mucous
membranes. J Am Acad
- Carrozzo M, Brancatello F, Dametto E, et al.
Hepatitis C virus-associated oral lichen planus: is the
geographical heterogeneity related to HLA-DR6? J Oral
Pathol Med. 2005;34:204-208.
- Gonzalez-Moles MA, Scully C, Gil-Montoya JA. Oral lichen
planus: controversies surrounding malignant
transformation. Oral Dis. 2008;14:229-243.
- Eisen D. The clinical manifestations and treatment of oral
lichen planus. Dermatol Clin.
- Passeron T, Lacour JP, Fontas E, et al. Treatment
of oral erosive lichen planus with 1% pimecrolimus cream: a
double-blind, randomized, prospective trial with measurement of
pimecrolimus levels in the blood. Arch
- Eisen D, Ellis CN, Duell EA, et al. Effect of
topical cyclosporine rinse on oral lichen planus. A double-blind
analysis. N Engl J Med. 1990;323:290-4.
- Corrocher G, Di Lorenzo G, Martinelli N, et al.
Comparative effect of tacrolimus 0.1% ointment and clobetasol 0.05%
ointment in patients with oral lichen planus. J Clin
- Scully C, Eisen D, Carrozzo M. Management of Oral Lichen
Planus. Am J Clin Dermatol.2 000;5:287-306.