oral lichen planus (OLP)

Last edited 09/2020

A white asymptomatic fine streaking, particularly of the buccal mucosa, is found in 50% of patients with lichen planus.

All age groups can be affected (usually the onset occurs in the fifth or sixth decade) (1). It can present in several forms:

• atrophic }
• bullous } can cause mild to severe pain
• erosive }
• papular
• pigmented
• plaquelike
• reticular - most common form, usually asymptomatic - typical clinical features are represented by bilaterally located white papules that enlarge and coalesce to form reticulations, the so-called Wickham's striae
(1,2,3,4,5)

Oral lichen planus is a chronic disorder of the oral cavity that rarely undergoes spontaneous remission (5)

• affects approximately 1% to 2% of the population, mainly middle-aged adults
• women are slightly more likely than men to have this condition
• commonly affected sites are the buccal mucosa bilaterally, the borders and dorsum of the tongue, and the gingiva
• palate (either hard or soft), the lips and the floor of the mouth are rarely involved
• has a fluctuating course with apparent spontaneous exacerbations and improvements in disease activity within an individual patient
• people with OLP have an increased risk of developing oral squamous cell carcinoma (SCC)

Clinical appearance alone, particularly when showing the "classic" reticular form, may sometimes allow a definitive diagnosis

• biopsy of suspected oral lichen planus is prudent clinical practice
• histopathology can be subjective and non-specific - however it can be useful to exclude dysplasia and SCC
• when exclusive gingival or predominantly erosive or ulcerative lesions are present, immunological tests are warranted to achieve a proper diagnosis (4)

Oral lesions are more difficult to manage:

Troublesome oral symptoms can be treated as follows (3):

• Topical analgesia is available as a mouthwash and spray eg Difflam ® 
• A number of topical anti-inflammatories can be used as a gargle for 2-4 minutes, 3-4 times a day
  • Betamethasone 500 microgram soluble tablet dissolved in 10 ml of water 
  • Flixonase ® Nasule ® drop 400 micrograms dissolved in 10 ml of water 
  • Doxycycline 100 mg dispersible tablets have both anti-inflammatory and antibacterial properties
• there are various methods of delivering topical steroids to the oral mucosa (e.g. lozenges, pastes) but responses are often indifferent and secondary candida infection is all too common (1,2)
• there is data that suggest that tacrolimus or pimecrolimus may have a role in the management of oral lichen planus (1)
• in patients with chronic oral lichen planus then these patients should be kept under surveillance for the development of oral cancer (1)
• very low-certainty evidence suggests that calcineurin inhibitors, specifically tacrolimus, may be more effective at resolving pain than corticosteroids (5)
  

Reference:

1. Dermatology in Practice 2004; 12 (2): 25-6.
2. Usatine R, Tinitigan M. Diagnosis and Treatment of Lichen Planus. American Family Physician. 2011 Jul1;84 (1):53-60.
3. Primary Care Dermatological Society. Lichen planus (Accessed 2/9/2020)
4. Dorothea C et al. Oral lichen planus. Arch Dermatol. 2007;143(4):511-515
5. Lodi G et al. Interventions for treating oral lichen planus: corticosteroid therapies. Cochrane Systematic Review;28 February 2020