A 48 Year Old Male Alcoholic with Multiple Plaques



Figure 6.1
Purple polygonal planar papules of lichen planus




  • Morsicatio buccarum (oral mucosa)—This diagnosis refers to the whitish bite line that can be seen on buccal mucosa, and is typically bilateral, and associated with cheek biting. This would not explain the rest of his physical findings, however.





      Further Workup

      While the patient is hospitalized for his withdrawal symptoms, a dermatology consult is placed and skin biopsy obtained. Liver function tests reveal a transaminitis, and hepatitis C antigen is positive. He is found to be HIV and RPR negative and other laboratory values are within normal limits, including hepatitis B serology.


      Diagnosis 

      Lichen planus

      While the precise etiology of lichen planus is unknown, an immunological mechanism involving CD8 + −mediated destruction of basal keratinocytes has been proposed, initiated by either an endogenous or exogenous antigenic stimulus. As described above, lesions are typically purplish in color, itchy, and may exhibit a phenomenon of koebnerization. Various clinical manifestations of LP include annular, hypertrophic, atrophic, ulcerative, bullous, linear, and pigmented. Additionally, LP of the scalp is termed lichen planopilaris, and is a form of scarring alopecia. There is an increased risk of developing squamous cell carcinoma in chronic lesions of oral LP [1]. Mucosal LP refers to that affecting the lining of the gastrointestinal tract (mouth, pharynx, esophagus, stomach, anus), larynx, and other mucosal surfaces including the genitals, peritoneum, ears, nose, bladder and conjunctiva of the eyes.

      Several studies have looked at the association between LP and hepatitis C, with mixed results. A systematic review from 2010 found that lichen planus patients have a significantly higher risk than controls of being hepatitis C virus (HCV) seropositive, and a similar odds ratio of having lichen planus was found among HCV patients [2]. However, subgroup analysis revealed that the strength of this association varied geographically. Certainly a lichen planus patient with positive risk factors for HCV should undergo serological testing.



      Conventional Treatment Strategies






      • Topical approaches—High-potency topical steroids are typically first-line treatment, and can be compounded in adhesive vehicles (Orabase™) for application to mucosal surfaces [3]. Non-steroidal anti-inflammatory medications such as topical tacrolimus 0.1 % ointment can also be applied twice daily to non-mucosal surfaces. Additionally, viscous lidocaine compounded with diphenhydramine and a calcium carbonate-based antacid (Maalox™) can be used as a mouth rinse prior to meals for pain relief in oral LP.


      • Systemic approaches—Phototherapy in the form of narrow-band ultraviolet B can be useful in some forms of cutaneous lichen planus [4], but in patients with darker skin types there is a higher risk of post-inflammatory hyperpigmentation.

      Oral prednisone in doses of 0.5–1 mg/kg tapered slowly over 6–8 weeks can be used in severe or erosive disease. Intramuscular steroids injections (triamcinolone 40 mg/cc) can also confer several weeks of remission at a time. Unfortunately, disease relapse with steroid taper is common [3], and the longer time course of treatment increases the myriad risks of steroid side effects.

      Oral acitretin in doses of 10–50 mg/day, systemic methotrexate 5–25 mg/week, oral cyclosporine 3–5 mg/kg divided BID, and other immunosuppressants such as mycophenolate mofetil are employed for widespread or recalcitrant disease, but do require periodic laboratory monitoring for systemic side effects.

      Additionally, referral to other services such as gastroenterology or otolaryngology should be directed by a patient’s review of systems.

      • Tags:
      Apr 7, 2016 | Posted by in Dermatology | Comments Off on A 48 Year Old Male Alcoholic with Multiple Plaques

      Full access? Get Clinical Tree
      Get Clinical Tree app for offline access