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CASE REPORT
Year : 2018  |  Volume : 7  |  Issue : 4  |  Page : 288-291

Ulcerative lichen planus of lower lip – Case series


1 Department of DVL, Government Medical College, Nizamabad, India
2 Department of Oral Medicine, Government Dental College, Hyderabad, India
3 Department of D.V.L., Gandhi Medical College, Hyderabad, Telangana, India

Date of Web Publication10-Jan-2019

Correspondence Address:
Dr. Sudha Rani Chintagunta
Plot No. #5, Jupiter Colony, Kakaguda, Karkhana, Secunderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JDRNTRUHS.JDRNTRUHS_64_18

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  Abstract 


Lichen planus (LP) involving lips is a rare occurrence. It can occur isolated or with cutaneous or oral lesions. Clinical features include radiated streaks, lace-like papules, and erosions, usually confined to vermilion border. When isolated, it should be differentiated from cheilitis, discoid lupus erythematosus, and other ulcerative conditions. Herein, we report nine cases of LP involving lower lip, with persistent ulceration and crusting. Of the nine patients in our series, eight were females and one was male. Age varied from 25 to 44 years, and the average duration was 4 years. Cutaneous examination revealed diffuse involvement of the lower lip with ulceration, hemorrhagic crusting in eight and localized involvement in one. Biopsy was suggestive of LP with no dysplasia or malignancy. Treatment with topical corticosteroids, tacrolimus, sunscreens, and Hydroxy chloroquine has shown variable results with frequent relapses. Because lesions on the lips are highly susceptible to actinic changes and malignant transformation, these patients require regular and long-term follow-up.

Keywords: Lichen planus, lower lip, ulcerative lesions


How to cite this article:
Chintagunta SR, Sana SN, Gopidi PJ. Ulcerative lichen planus of lower lip – Case series. J NTR Univ Health Sci 2018;7:288-91

How to cite this URL:
Chintagunta SR, Sana SN, Gopidi PJ. Ulcerative lichen planus of lower lip – Case series. J NTR Univ Health Sci [serial online] 2018 [cited 2019 Sep 16];7:288-91. Available from: http://www.jdrntruhs.org/text.asp?2018/7/4/288/249832




  Introduction Top


Oral lichen planus (OLP) is a relatively common disorder with unknown etiology. Among the six clinical variants of OLP described by Andreasen, reticular, erosive/ulcerative, papular, plaque-like, atrophic, and bullous, reticular is the most common variant. In the oral cavity, the commonly involved sites are buccal mucosa, tongue, gingival, and floor of mouth.[1] It rarely occurs on the lips, usually associated with oral lesions. Herein, we report nine cases of LP involving lower lip, with persistent ulceration and crusting.


  Case Report Top


Nine patients presented with chronic ulceration of the lower lip in a 2-year period. Of the nine patients, eight were females and one was male. The age of the patients varied from 25 to 44 years. The duration varied from 6 months to 4 years. There was no history of dental fillings or drug intake. No history of prolonged sun exposure or seasonal variation was seen. Physical examination showed diffuse involvement of the lower lip with marked swelling, erosions, ulceration with violaceous streaks, and crusting in eight patients [Figure 1], [Figure 2], [Figure 3], [Figure 4] and localized scaling, crusting, and pigmentation in one. There were no lesions in the oral cavity or adjacent skin. Systemic and general examination was normal. Differential diagnosis of LP, actinic cheilitis, and discoid lupus was considered. Histology showed prominent granular layer with band-like dense inflammatory infiltrate composed of lymphocytes and plasma cells [Figure 5] in seven cases. Additionally, dilated, congested vessels and focal ulceration were seen in two [Figure 6].
Figure 1: Marked swelling, erosion, oozing and crusting on the lower lip

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Figure 2: Erosions with adherent crusting on the lower lip

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Figure 3: Erythema, scaling, hemorrhagic crusting

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Figure 4: Ulceration, crusting with violaceous margins involving the lower lip

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Figure 5: Hyperkeratosis, acanthosis, prominent granular layer with band-like dense inflammatory infiltrate in the subepithelium composed of lymphocytes and plasma cells

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Figure 6: Subepithelium showing dense inflammatory infiltrate and dilated, congested vessels and focal ulceration

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Actinic cheilitis is common in middle-aged individuals with prolonged sun exposure. Lower lip involvement is common; other observations include rough, scaly keratotic patches, fissures, ulceration, and sandpaper feeling on palpation.[2] Histology shows hyperplasia, solar elastosis, dysplasia, inflammation, and vasodilatation.

Discoid lupus is common in females between 20 and 40 years. Clinical manifestations include well-demarcated discoid lesions or diffuse cheilitis. The lesions spread from vermilion to the surrounding skin, obscuring the limits of the vermilion zone. Associated oral lesions appear as well-demarcated, round, or irregular red areas with atrophy or ulceration, white radiating keratotic striae, and telangiectases.[3] Histopathology shows keratotic plugs, focal liquefaction degeneration of basal layer, and perivascular lymphocytic infiltration.

Based on the clinicopathological correlation, diagnosis of LP of the lip was made. All the patients treated with topical corticosteroids, tacrolimus, sunscreens, and HCQs 200 mg showed variable results with frequent relapses.


  Discussion Top


Isolated LP of the lip is a very rare occurrence. It can occur isolated or in association with cutaneous and/or oral LP. The lesions are commonly observed on the lower lip, followed by concomitant lesions on the upper and lower lips, and very rarely only on the upper lip.[4] Typical flat-topped, violaceous papules are uncommon on the lips, whereas erosions, radiated streaks, lace-like lesions, and annular plaques are common. Morphologically, atrophic–erosive form is the most common form in isolated LP of the lip. The lesions are always confined to the vermilion and do not reach the labial skin by blurring the sharp line of the vermilion border.

The incidence of labial LP is unknown; only limited data are available in the form of few case reports and case series.[4],[5] In a study by Xue et al.,[4] 8.9% of the cases had isolated labial lesions. Sharma and Maheshwari, Nanda et al., and Petruzzi et al. reported 4, 3, and 10 cases of isolated labial LP, respectively.[6],[7],[8] The prevalence of isolated LLP reported by Nuzzolo et al. ranges from 0.5% to 8.9%. In our series, male:female ratio was 1:8. The mean age was 34.7 years and the mean duration was 21.5 months. In the studies by Petruzzi et al. and Nuzzolo et al., the mean age was 62.7 and 71.8 years, respectively, with male predominance. The mean duration of LP was 6.1 months. A review article by Nuzzolo et al.[9] also reported male predominance with a mean age of 45.3 years.

Among the six clinical variants of OLP, the atrophic–erosive form was the most common in isolated LP of the lip; in our series also, erosive form was the common type observed.

Topical corticosteroids are the first-line therapy for mucosal LP. Immunomodulatory agents such as cyclosporine, tacrolimus, or retinoids are used in patients not responding to topical steroids. 5% imiquimod cream also showed good results. Systemic treatment with prednisolone, PUVA, acitretin, methotrexate, azathioprine, and mycophenolate mofetil is used in severe and recalcitrant cases.

All patients improved with topical steroids, tacrolimus, and HCQs with frequent relapses. The serious complication of OLP is malignant transformation, which is reported to be 0.4%–5.8% with high risk in erosive and atrophic forms, and no malignancy or dysplasia was noticed in our series.


  Conclusion Top


LP confined to lip is a rare entity. Because lesions on the lips are highly susceptible to actinic changes and malignant transformation, biopsy may be done in all cases who present with ulcerative lesions. These patients require regular and long-term follow-up. Protective clothing, less outdoor activities, and sunscreens are recommended.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Brown RS, Bottomley WK, Puente E, Lavigne GJ. A retrospective evaluation of 193 patients with oral lichen planus. J Oral Pathol Med 1993;22:69-72.  Back to cited text no. 1
    
2.
Kaugars GE, Pillion T, Svirsky JA, Page DG, Burns JC, Abbey LM. Actinic cheilitis: A review of 152 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88:181-6.  Back to cited text no. 2
    
3.
Orteu CH, Buchanan JAG, Hutchison I, Leigh IM, Bull RH. Systemic lupus erythematosus presenting with oral mucosal lesions: Easily missed? Br J Dermatol 2001;144:1219-23.  Back to cited text no. 3
    
4.
Xue JL, Fan MW, Wang SZ, Chen XM, Li Y, Wang L. A clinical study of 674 patients with oral lichen planus in China. J Oral Pathol Med 2005;34:467-72.  Back to cited text no. 4
    
5.
Nico MM, Fernandes JD, Lourenço SV. Lichen planus affecting the lips. J Clin Exp Dermatol Res 2015;6:6.  Back to cited text no. 5
    
6.
Sharma R, Maheshwari V. Childhood lichen planus: A report of fifty cases. Pediatr Dermatol 1999;16:345-8.  Back to cited text no. 6
    
7.
Nanda A, Al-Ajmi HS, Al-Sabah H, Al-Hasawi F, Alsaleh QA. Childhood lichen planus: A report of 23 cases. Pediatr Dermatol 2001;18:1-4.  Back to cited text no. 7
    
8.
Petruzzi M, De Benedittis M, Pastore L, Pannone G, Grassi FR, Serpico R. Isolated lichen planus of the lip. Int J Immunopathol Pharmacol 2007;20:631-5.  Back to cited text no. 8
    
9.
Nuzzolo P, Celentano A, Bucci P, Adamo D, Ruoppo E, Leuci S, et al. Lichen planus of the lips: An intermediate disease between the skin and mucosa? Int J Dermatol 2016;55:e473-81.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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