Erosive Oral Lichen Planus May Flag Genital Lesions

PORTLAND, ORE. — Gingival lichen planus, particularly forms that are erosive, ulcerative, or bullous, should raise the red flag of suspicion about the presence of genital lesions, Dr. Roy S. Rogers III said at the Pacific Northwest Dermatological annual scientific meeting.

“The gynecologists usually don't ask about the mouth or look there. The dentists certainly don't ask about the vulva, nor do they look there. Neither do the ENT [ear, nose, throat] physicians,” said Dr. Rogers, professor of dermatology at the Mayo Clinic in Rochester, Minn.

“It's really up to us to be the internist and externist [in order to diagnose extraoral lichen planus],” he said.

Studies suggest that genital lesions are present in 1 of 5 women and 1 in 20 men with oral lichen planus.

When oral lesions are reticular, linear, and feature papular and plaquelike lesions, “these are low-hanging fruit and are rather easy to deal with,” he said.

In fact, many such lesions are asymptomatic and discovered by a dentist during a routine examination.

It is lesions that are atrophic, erosive, ulcerative, and/or bullous that can be extremely painful, often with extraoral manifestations. “They require our very expert care,” Dr. Rogers said.

Vulvovaginal lesions may be eroded, leading in some cases to desquamatous vaginitis. Known as vulvovaginal-gingival syndrome, this form of the disease is chronic and may involve other areas of the body, including the skin, scalp, nails, ear canal, and esophagus.

Much rarer, but clinically similar, is peno-gingival syndrome in men, which is characterized by desquamative gingivitis and penile involvement.

Histopathology and immunopathology usually have findings typical of classic lichen planus lesions.

Therapy can be challenging, but may include the topical immunomodulator tacrolimus, systemic and topical corticosteroids, hydroxychloroquine, cyclosporine, dapsone, griseofulvin, interferon α-2b, retinoids, and mycophenolate mofetil.

Topical tacrolimus is particularly effective in reducing symptoms of both oral and vulvar lichen planus, which is a T cell-mediated disorder, he said.

Studies performed by Dr. Rogers' group at the Mayo Clinic found that the application of topical tacrolimus produced meaningful symptomatic improvement in 33 of 37 patients with oral lichen planus and 15 of 16 patients with vulvar lichen planus within about 1 month (Arch. Dermatol. 2004;140:1,508–12; Arch. Dermatol. 2004;140:715–20).

Burning and stinging were reported in roughly one-third of patients but became less pronounced over time.

In both studies, discontinuation of treatment resulted in a return of lesions; however, they were less severe and could be controlled with reinitiation of tacrolimus treatment.

Meticulous oral hygiene is critically important to control perioral disease, because patients tend to develop secondary candidiasis that may become koebnerized from poor oral hygiene, Dr. Rogers said.

Patients with oral lichen planus face a 1% lifetime risk of malignant transformation of their lesions. “Tell them you want them to be seen every 6 months by their dentist and/or by you,” he said.

Dr. Rogers reported no financial disclosures.

PORTLAND, ORE. — Gingival lichen planus, particularly forms that are erosive, ulcerative, or bullous, should raise the red flag of suspicion about the presence of genital lesions, Dr. Roy S. Rogers III said at the Pacific Northwest Dermatological annual scientific meeting.

“The gynecologists usually don't ask about the mouth or look there. The dentists certainly don't ask about the vulva, nor do they look there. Neither do the ENT [ear, nose, throat] physicians,” said Dr. Rogers, professor of dermatology at the Mayo Clinic in Rochester, Minn.

“It's really up to us to be the internist and externist [in order to diagnose extraoral lichen planus],” he said.

Studies suggest that genital lesions are present in 1 of 5 women and 1 in 20 men with oral lichen planus.

When oral lesions are reticular, linear, and feature papular and plaquelike lesions, “these are low-hanging fruit and are rather easy to deal with,” he said.

In fact, many such lesions are asymptomatic and discovered by a dentist during a routine examination.

It is lesions that are atrophic, erosive, ulcerative, and/or bullous that can be extremely painful, often with extraoral manifestations. “They require our very expert care,” Dr. Rogers said.

Vulvovaginal lesions may be eroded, leading in some cases to desquamatous vaginitis. Known as vulvovaginal-gingival syndrome, this form of the disease is chronic and may involve other areas of the body, including the skin, scalp, nails, ear canal, and esophagus.

Much rarer, but clinically similar, is peno-gingival syndrome in men, which is characterized by desquamative gingivitis and penile involvement.

Histopathology and immunopathology usually have findings typical of classic lichen planus lesions.

Therapy can be challenging, but may include the topical immunomodulator tacrolimus, systemic and topical corticosteroids, hydroxychloroquine, cyclosporine, dapsone, griseofulvin, interferon α-2b, retinoids, and mycophenolate mofetil.

Topical tacrolimus is particularly effective in reducing symptoms of both oral and vulvar lichen planus, which is a T cell-mediated disorder, he said.

Studies performed by Dr. Rogers' group at the Mayo Clinic found that the application of topical tacrolimus produced meaningful symptomatic improvement in 33 of 37 patients with oral lichen planus and 15 of 16 patients with vulvar lichen planus within about 1 month (Arch. Dermatol. 2004;140:1,508–12; Arch. Dermatol. 2004;140:715–20).

Burning and stinging were reported in roughly one-third of patients but became less pronounced over time.

In both studies, discontinuation of treatment resulted in a return of lesions; however, they were less severe and could be controlled with reinitiation of tacrolimus treatment.

Meticulous oral hygiene is critically important to control perioral disease, because patients tend to develop secondary candidiasis that may become koebnerized from poor oral hygiene, Dr. Rogers said.

Patients with oral lichen planus face a 1% lifetime risk of malignant transformation of their lesions. “Tell them you want them to be seen every 6 months by their dentist and/or by you,” he said.

Dr. Rogers reported no financial disclosures.

PORTLAND, ORE. — Gingival lichen planus, particularly forms that are erosive, ulcerative, or bullous, should raise the red flag of suspicion about the presence of genital lesions, Dr. Roy S. Rogers III said at the Pacific Northwest Dermatological annual scientific meeting.

“The gynecologists usually don't ask about the mouth or look there. The dentists certainly don't ask about the vulva, nor do they look there. Neither do the ENT [ear, nose, throat] physicians,” said Dr. Rogers, professor of dermatology at the Mayo Clinic in Rochester, Minn.

“It's really up to us to be the internist and externist [in order to diagnose extraoral lichen planus],” he said.

Studies suggest that genital lesions are present in 1 of 5 women and 1 in 20 men with oral lichen planus.

When oral lesions are reticular, linear, and feature papular and plaquelike lesions, “these are low-hanging fruit and are rather easy to deal with,” he said.

In fact, many such lesions are asymptomatic and discovered by a dentist during a routine examination.

It is lesions that are atrophic, erosive, ulcerative, and/or bullous that can be extremely painful, often with extraoral manifestations. “They require our very expert care,” Dr. Rogers said.

Vulvovaginal lesions may be eroded, leading in some cases to desquamatous vaginitis. Known as vulvovaginal-gingival syndrome, this form of the disease is chronic and may involve other areas of the body, including the skin, scalp, nails, ear canal, and esophagus.

Much rarer, but clinically similar, is peno-gingival syndrome in men, which is characterized by desquamative gingivitis and penile involvement.

Histopathology and immunopathology usually have findings typical of classic lichen planus lesions.

Therapy can be challenging, but may include the topical immunomodulator tacrolimus, systemic and topical corticosteroids, hydroxychloroquine, cyclosporine, dapsone, griseofulvin, interferon α-2b, retinoids, and mycophenolate mofetil.

Topical tacrolimus is particularly effective in reducing symptoms of both oral and vulvar lichen planus, which is a T cell-mediated disorder, he said.

Studies performed by Dr. Rogers' group at the Mayo Clinic found that the application of topical tacrolimus produced meaningful symptomatic improvement in 33 of 37 patients with oral lichen planus and 15 of 16 patients with vulvar lichen planus within about 1 month (Arch. Dermatol. 2004;140:1,508–12; Arch. Dermatol. 2004;140:715–20).

Burning and stinging were reported in roughly one-third of patients but became less pronounced over time.

In both studies, discontinuation of treatment resulted in a return of lesions; however, they were less severe and could be controlled with reinitiation of tacrolimus treatment.

Meticulous oral hygiene is critically important to control perioral disease, because patients tend to develop secondary candidiasis that may become koebnerized from poor oral hygiene, Dr. Rogers said.

Patients with oral lichen planus face a 1% lifetime risk of malignant transformation of their lesions. “Tell them you want them to be seen every 6 months by their dentist and/or by you,” he said.

Dr. Rogers reported no financial disclosures.