What Is Erosive Lichen Planus?
Erosive lichen planus (ELP) is a chronic autoimmune disorder affecting mucosal surfaces, including the oral cavity, genital areas, and sometimes the skin. Unlike typical lichen planus, which manifests as papular eruptions, ELP presents with painful erosions and ulcerations, leading to significant discomfort and reduced quality of life.
Causes and Pathogenesis
The exact cause of erosive lichen planus remains unclear, but it is believed to result from an abnormal immune response. The following factors may contribute:
- Autoimmune Mechanism: T-cell-mediated destruction of basal keratinocytes.
- Genetic Predisposition: A family history of autoimmune disorders may increase susceptibility.
- Triggers: Certain medications, dental restorations (e.g., amalgam fillings), infections, and stress can exacerbate symptoms.
- Underlying Conditions: Hepatitis C infection has been linked to lichen planus in some patients.
Pathophysiology
The inflammatory process in ELP involves the activation of T-lymphocytes, leading to basal cell apoptosis and subepithelial inflammatory infiltration. The following mermaid diagram illustrates the pathogenesis:
Common Symptoms
Erosive lichen planus can affect multiple areas, with symptoms varying based on the site of involvement:
Oral Erosive Lichen Planus (OELP)
- Painful, burning sensation in the mouth
- Red, ulcerated lesions on the gums, tongue, and inner cheeks
- White striations (Wickham’s striae) surrounding the lesions
- Increased sensitivity to spicy and acidic foods
- Bleeding or difficulty eating and speaking
Genital Erosive Lichen Planus
- Painful erosions and ulcerations in the vaginal or penile mucosa
- Burning sensation and discomfort during urination or intercourse
- Scarring and possible narrowing of affected areas (vaginal stenosis or phimosis)
Cutaneous Erosive Lichen Planus
- Ulcerative lesions on the skin, often with a violaceous hue
- Pruritus (itching) and pain
- Chronic cases may result in scarring and pigment changes
Diagnosis and Differential Diagnosis
Erosive lichen planus is diagnosed through clinical examination and confirmed via biopsy. Key diagnostic tools include:
- Histopathology: Shows characteristic basal layer degeneration and band-like lymphocytic infiltration.
- Direct Immunofluorescence: Helps differentiate ELP from autoimmune blistering diseases.
- Blood Tests: May be conducted to rule out associated conditions like hepatitis C.
Conditions to Differentiate From:
- Pemphigus vulgaris
- Mucous membrane pemphigoid
- Systemic lupus erythematosus
- Erythema multiforme
- Chronic ulcerative stomatitis
Treatment Options
There is no permanent cure for erosive lichen planus, but treatment focuses on symptom relief and inflammation control.
Topical Therapies
- Corticosteroids: First-line treatment; includes clobetasol and fluocinonide gels.
- Calcineurin Inhibitors: Tacrolimus or pimecrolimus for steroid-resistant cases.
- Mouth Rinses: Corticosteroid or anesthetic rinses for oral lesions.
Systemic Treatments
- Oral Corticosteroids: Used in severe, widespread cases.
- Immunosuppressants: Methotrexate, azathioprine, or cyclosporine for refractory cases.
- Biologic Therapy: Emerging treatments targeting immune pathways, such as rituximab.
Adjunctive Therapies
- Phototherapy (PUVA/NB-UVB): Beneficial for cutaneous lesions.
- Pain Management: Lidocaine gels and systemic analgesics.
- Nutritional Support: Avoiding spicy, acidic foods and ensuring a balanced diet.
Complications and Prognosis
If left untreated, erosive lichen planus can lead to severe complications:
- Secondary Infections: Open ulcerations may be prone to bacterial or fungal infections.
- Scarring: Chronic inflammation can cause permanent mucosal or cutaneous scarring.
- Malignant Transformation: A small percentage of oral erosive lichen planus cases may progress to oral squamous cell carcinoma, necessitating regular monitoring.
Preventive Measures and Lifestyle Adjustments
While there is no guaranteed prevention, certain lifestyle adjustments can help reduce flare-ups:
- Maintain Oral Hygiene: Regular dental check-ups and non-irritating oral care products.
- Avoid Known Triggers: Identify and eliminate potential aggravating factors such as certain foods, stress, or medications.
- Stress Management: Mindfulness, relaxation techniques, and counseling may help prevent exacerbations.
- Regular Follow-ups: Monitoring for signs of malignancy and ensuring effective symptom management.
