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The Lichen
planus El Liquen plano. *********************************** AB: INTRODUCTION: The association of lichen planus with liver diseases is
now well established. Lichen planus following hepatitis B vaccination are
much more unusual. We report here the fifth case of this kind. CASE REPORT:
A 16 years old girl developed a purely cutaneous lichen planus one week
after the first injection of hepatitis B vaccine Gen Hevac B (Institut
Pasteur), which appeared again 3 days after the second injection. The
histologic features shown lichenoid pattern with intense keratinocytes
necrosis more in favor of lichenoid drug eruption than lichen planus.
DISCUSSION: According to our knowledge, only four similar cases have been
previously reported. Comparison between the different vaccines used shows
that only the HBs antigen and its epitope S could be involved in the lichen
planus eruption. Our case is specific due to the early appearance of the
eruption after the first injection and by its histologic features.
CONCLUSION: New cases of lichen planus following hepatitis B vaccination
should help to explain the causal relationship between lichen planus
eruption and hepatitis B vaccination. AB: Lichen planus is an immunologically mediated skin or mucous disease, which has recently been described in some patients with hepatitis C virus-related liver disease. We report 5 new cases of the association of hepatitis C with lichen planus, to be added to the 15 cases published in the literature. The sex ratio (female/male) was of 1.2. Lichen planus occurred more frequently in chronic active hepatitis (2/3 of cases) than in cirrhosis (1/3 of cases). Lichen planus manifestations were only mucous (30%), only cutaneous (40%) or both (30%). Mucous lesions were mainly observed in patients with cirrhosis (3/4 of cases). The onset of skin and hepatic manifestations was variable, with liver disease as the most frequent revealing symptom (60%). The influence of interferon remains unclear. However, it seemed to trigger more than to relieve lichen planus.
============================================================= AB: The purpose of this prospective study was to evaluate the short-term and long-term clinical efficacy of levamisole used with low-dose prednisolone in patients with refractory oral lichen planus. Twenty-three patients with OLP who had been treated unsuccessfully with other modalities were given 150 mg/day levamisole and 15 mg/day prednisolone for 3 consecutive days each week. Twelve patients showed dramatic remission of signs and symptoms within 2 weeks, whereas 11 had partial remission. All 23 reported significant pain relief and showed no evidence of erosive oral lichen planus after 4 to 6 weeks of treatment. All 23 also remained free from symptoms for 6 to 9 months after the treatment ended. There were few side effects from this treatment besides minor skin rash, headache, and insomnia from the levamisole in three cases. We conclude that the addition of levamisole to prednisolone may produce improved results in the management of erosive oral lichen planus. MESH: Administration,-Oral; Adult-; Aged-;
Anti-Inflammatory-Agents,-Steroidal-therapeutic-use;
Biological-Response-Modifiers-therapeutic-use; Drug-Therapy,-Combination;
Follow-Up-Studies; Levamisole-therapeutic-use; Middle-Age;
Prednisolone-therapeutic-use; Prospective-Studies; Treatment-Outcome
MESH: *Anti-Inflammatory-Agents,-Steroidal-administration-and-dosage;
*Biological-Response-Modifiers-administration-and-dosage;
*Levamisole-administration-and-dosage; *Lichen-Planus,-Oral-drug-therapy;
Abstrato journal American Academy Dermatology Abril 1.998 Methods: Included in the study were 10 patients with widespread histopathologically proven lichen planus (LP) associated with intense pruritus of several months' duration. Patients were given 3 mg enoxaparin, subcutaneously once weekly; three patients received four injections, and seven patients received six injections. Results: In nine patients the itch disappeared within 2 weeks. Within 4 to 10 weeks in eight of these patients, there was complete regression of the eruption with residual postinflammatory hyperpigmentation; in one patient, there was marked improvement. In one patient, no effect was observed. Of the four patients who also had oral LP, only one showed improvement. No side effects were observed in any of the patients. Conclusion: These findings indicate that enoxaparin may be a simple,
effective treatment for cutaneous LP. (J Am Acad Dermatol 1998;38:564-8.)
Further investigations with a higher numbers of cases in
combination with the analysis of the viral gene expression as well as the
clinical and histological control of the corresponding regions are
necessary. The aim of these studies is to find out the prognostic value of
the HPV infection for this facultative premalignant disease. AB: Three patients with generalized lichen planus were treated with
interferon alfa-2b. The therapy was tolerated well by all patients with
only minor side effects. A response was observed within 2 to 3 weeks.
Itching and erythema decreased first, followed by gradual flattening and
disappearance of papules and plaques after 8 to 10 weeks of treatment.
After 12 weeks, therapy was discontinued after stepwise dosage reduction.
In two patients, minor lesions recurred during dosage reduction. Both
flares were controlled by readministration of interferon.
============================================================= Although about 65% of patients with cutaneous LP go into spontaneous remission after one year, such remissions have been estimated to occur in no more than 3% of patients with oral LP.5 The underlying mechanism causing LP is thought to be a T-cell mediated immune response against foreign or autogenous antigens.6 At least two thirds of the patients with LP are between the ages of 30-60 and the disease is uncommon in the very young and in the elderly.7 Oral lichen planus (LP), if erosive or disseminated can be very resistant to treatment. Oral LP has many clinical presentations, with some lesions requiring no treatment and others needing management for decades. Treatment rationale Topical corticosteroids should be considered the treatment of choice unless the disease is very extensive.1,2 Systemic therapy is reserved for those with severe, refractory disease.3 Oral hygiene1-3 and corrective dentistry1-4 play a major role in the management of LP and consultation with a dentist or oral medicine specialist may be helpful.6 Acitretin, combined with topical corticosteroid, can be effective, but should be reserved for patients who have not responded to corticosteroids alone. The retinoid should be used for several months and then tapered as patients improve.3 If acitretin is ineffective, other agents such as antimalarials, azathioprine or cyclosporine1 have been used. Dental treatment Indifferent oral hygiene leading to the formation of plaque and calculus exacerbates gingival LP, which may lead to severe gingivitis and periodontal disease.3 An optimal oral hygiene regimen should be instituted in all patients with oral LP, especially those with gingival involvement. Medical therapy should accompany oral hygiene measures.3
Certain oral clenching and sucking habits
can make LP erosive or ulcerative, and habit splints have helped to modify
these habits and reduce the inflammation.4 Oral trauma from ragged broken
teeth and sharp prostheses are provocative.1 There is some evidence that
the
presence of gold and mercury amalgam fillings may provoke oral lichenoid
reactions. Only a very small percentage of patients will respond to
improved oral hygiene and corrective dentistry without further
intervention.1,2
Lichen planus and hepatic disease ////CONTROVERSIAL, PUES LAS REFERENCIAS HABLAN DE ASOCIACION CON HEPATITIS B Y C//// Practice points: 1% of patients with oral LP will develop oral squamous cell carcinoma.2 T he relative importance of reversible causes of lichenoid eruptions, such as exposure to causative drugs (most commonly diuretics and non-steroidal anti-inflammatory agents), or hypersensitivity reactions to dental restorations has not been determined but a proper history should be obtained prior to instituting therapy.3 Secondary candidiasis should be suspected when acute exacerbations develop in patients being treated with chronic topical or systemic steroids or other forms of immunosuppression.3 There is increasing evidence that many women have concomitant lichen planus vulvar involvement, which either they are unaware of or decline to mention to their dermatologists. Female patients should be examined for vulvar involvement, or at least asked about symptoms.1 Penile lesions are common. There are significant histologic differences between idiopathic lichen planus and a lichenoid drug eruption. It's important to do a baseline biopsy to distinguish between these two entities and to have these biopsies read by a dermatopathologist. Patients who consume alcoholic beverages which contain flakes of
gold (Goldschlagger®, Gold Rush®, Gold Strike®) are at
increased risk
of developing generalized lichen planus. These drinks are more
popular in
Western Europe, especially with younger individuals, so in
such patients
inquiring about their patterns of alcohol consumption is
prudent.1
7.Arndt KA. Lichen planus. In: Fitzpatrick TB, Eisen AZ, Wolff K
et al,eds. Dermatology in General Medicine. New York: McGraw-Hill,
1993.
No large, well designed trials.4
Hydroxychloroquin is very effective when
topical therapy fails but many months of
treatment are required to realize its
benefits.3
Use oral corticosteroids with caution for a
short term. Azathioprine has also been
used as a steroid-sparing agent.
Cyclosporin does not appear to be better
than topical corticosteroids4 and is very
expensive.3,4 Extracorporeal photochemotherapy All seven patients in an open, prospective trial had complete remission of their chronic, erosive, oral LP, after 12 sessions over 1.5 months on average.9 Enoxaparin (a low
molecular weight
heparin)
Low doses given to 10 patients with
intensly pruritic LP produced complete
remission of non-oral skin lesions in eight
patients and marked improvement in one;
oral lesions improved in one out of four
patients with oral LP.10 |
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Produced by Dr. José Lapenta R.
Dermatologist
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