By Gary M. White, MD
The typical Wickham striae of lichen planus.
Oral lichen planus (OLP) commonly occurs on the buccal mucosa but may be seen on the tongue, gingiva and lips as well. OLP may occur in isolation, in association with genital lesions (see erosive, vulvovaginal LP) or along with cutaneous lesions. When it accompanies cutaneous lesions, oral involvement helps confirm the diagnosis. Squamous cell carcinoma develops in about 1% of patients with OLP [JAAD 2002;46;207].
A white, reticulated, lace-like lesion (Wickham striae) on the buccal mucosa, often bilaterally, is characteristic. Erosions may occur. White plaques may form on the tongue and lips. The patient may complain of stinging or burning, especially when eating. Any dental work should be noted as allergic contact dermatitis to oral metals can simulate lichen planus.
Treatment is not necessary for asymptomatic OLP. A potent topical steroid gel or ointment applied 3-5 times a day is a simple first-line intervention. Dexamethasone 0.5 mg/5 mL sipped 1 teaspoon orally and held in the mouth for several minutes (swish and spit) has been used. Fluticasone propionate spray (50 ug aqueous solution-nasal spray 2 puffs QID) was helpful [JAAD 2002;47;271]. Adverse effects included bad taste and smell, difficulty in application, sore throat, red, painful tongue, swollen mouth, nausea and candidiasis.
Tacrolimus 0.03-0.1% BID has been reported effective for erosive LP [BJD 1999;140;338]. The main side effect is burning. Retinoic acid has been used for thick lesions.
Oral alitretinoin was effective for oral LP in a study of 10 patients. [JEADV 2016;30;293]. Oral mycophenolate mofetil 500-1000 BID can be beneficial [JAAD 2016;74;1073]. Apremilast has been used 3 patients with success [J Drugs Dermatol 2016;15;1026].
If these measures fail, hydroxychloroquine (e.g. 200-400 mg/day) can be very effective. Oral CSA (e.g. as an oral rinse, or by applying several drops of 100 mg/mL of Sandimmun oral solution using the fingers BID) may be tried. An oral prosthesis has been used to occlude CSA. For significant gingival involvement, brushing should be very gentle, and a sponge may be substituted for a brush. A biopsy to rule out SCC should be done of unresponsive or suspicious lesions as SCC develops in about 1% of patients.
Involvement of the lips.
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