Journal of Medicine, Radiology, Pathology & Surgery (2017), 4, 11–14

CASE REPORT

Erosive lichen planus: A case report

Lakshmi Balraj1, Tejavathi Nagaraj1, Haritma Nigam1, Sida Tagore2
1
Department of Oral Medicine and Radiology, Sri Rajiv Gandhi College of Dental Sciences & Hospital, Bengaluru, Karnataka, India, 2Department of General
Pathology, Sri Rajiv Gandhi College of Dental Sciences & Hospital, Bengaluru, Karnataka, India

Keywords Abstract
Erosive lichen planus, topical corticosteroids, Lichen planus (LP) is a chronic inflammatory autoimmune mucocutaneous disease
triamcinolone acetonide
affecting about 2% of the population. There are three basic forms of oral LP (OLP)
which includes hypertrophic, erythematous, and bullous forms. The erosive form is the
Correspondence:
Dr. Lakshmi Balraj, Department of Oral
second most common form of OLP following the reticular type. This case report reviews
Medicine and Radiology, Sri Rajiv Gandhi the clinical approach to an erosive variant of OLP; wherein, the patient was educated,
College of Dental Sciences & Hospital, counseled about the chronicity of the condition and also about its high risk of malignant
Cholanagar, Bengaluru - 560 032, transformation; immediate biopsy being prompted; followed by the institution of
Karnataka, India. Phone: +91-9742504911. appropriate, timely treatment.
E-mail: [email protected]

Received: 22 December 2016

Accepted: 28 January 2017

doi: 10.15713/ins.jmrps.82

Introduction type lesion, erosive OLP (EOLP) presents with symptoms

ranging from intermittent mild pain to severe discomfort and
Lichen planus (LP) is a chronic inflammatory autoimmune
carries an increased risk malignant transformation. Hence,
mucocutaneous disease affecting about 2% of the population.[1]
it is an important for all clinicians to be aware of the clinical
Classic LP typically presents as pruritic, polygonal, purplish
presentations and provide prompt palliation to the erosive
papules, and plaques (described using the 6 Ps); many variants
forms affecting the oral cavity.[4]
in morphology and location also exist, including oral, nail,
This article presents a long-standing case of an erosive form of
linear, annular, erosive, atrophic, hypertrophic, inverse, eruptive,
LP affecting a middle-aged female in her 7th decade of life.
bullous, ulcerative, LP pigmentosus, lichen planopilaris,
vulvovaginal, actinic, LP-lupus erythematosus overlap syndrome,
and LP pemphigoides.[2] Case Report
The sites involved over the skin include the flexor surfaces of
the legs and arms, especially the wrists and elbows. The nail beds A 78-year-old female patient had reported to the Department of
may also be affected with resultant ridging, grooving, pterygium, Oral Medicine and Radiology with a chief complaint of burning
onychorrhexis, and complete loss of the nail. Involvement of sensation of the entire oral cavity that started almost 1  year
the scalp involvement if ignored and left untreated can lead back which was insidious in onset and moderates in nature and
to scarring and alopecia. In a dental setting, cutaneous LP is aggravated on having spicy food. Dental history revealed that she
observed in about one-third of the patients diagnosed with oral has had uneventful extractions and prosthetic fabrications.
LP (OLP). In contrast, two-third of patients seen in dermatologic The patient gave a medical history of being hypertensive and
clinics exhibit OLP.[3] taking medications for same since 12  years. Personal history
The erosive form is the second most common type of OLP. revealed that she had a mixed diet and had no deleterious
Variants of the erosive form include atrophic and bullous habits whatsoever. At the time of consultation, she was under
forms. It clinically manifests as a mixture of erythematous and considerable stress due to some family related issues.
ulcerated areas bounded by finely radiating keratotic striae. Extraorally, there was no gross changes or abnormalities
Unlike the keratotic variants such as reticular and plaque- detected [Figure 1]. On intraoral examination, there was the

Journal of Medicine, Radiology, Pathology & Surgery ● Vol. 4:1 ● Jan-Feb 2017 11
Balraj, et al. Erosive lichen planus: A case report

presence of two discrete plaques on the left buccal mucosa which

was surrounded by erythematous erosive areas approximately
of size 2.5 cm × 3 cm, opposite premolar – molar region. These
erythematous areas were further bounded by straight sharp
angular abruptly ending whitish striae [Figure  2]. The right
buccal mucosa exhibited faint grayish white striae arranged in
an annular lacy pattern with mild melanin pigmentation at the
periphery [Figure 3]. Certain erosive erythematous areas were
observed over the edentulous posterior regions of the crest
of maxillary alveolar ridge. All the inspection findings were
confirmed on palpation during which the lesions on both sides
were found to be non-scrapable and also mildly tender over
the left buccal mucosa. Considering the clinical presentation
and other related clinical history findings, the case was
provisionally diagnosed as erosive LP. Differential diagnoses
considered for this case included lupus  erythematosus,
Figure 1: Front profile view
pemphigus vulgaris, and atrophic candidiasis.
The patient was convinced to undergo incisional biopsy,
before which all routine blood investigations were done. Fasting
blood sugar and the blood pressure were found to be within
the normal limits. Subsequent histopathological examination
revealed areas of epithelial atrophy and basal cell degeneration
with the presence of a dense subepithelial band of chronic
inflammatory cell infiltration. All these features were consistent
with that of an erosive LP, thereby confirming our provisional
diagnosis.
The patient was put on a course of topical corticosteroid
therapy of 0.1% triamcinolone acetonide oral paste (available as
“kenacort” commercially) for 3 months. The patient was advised
to apply the paste locally over lesional areas 3 times daily after
meals and was recalled after 7 days. During the recall visit, there
was considerable remission of the lesion and in the symptoms as
well. She was educated about the chronicity and recurrence of
the disease entity which warrants the need for regular follow-up
Figure 2: Plaques within erythematous areas surrounded by whitish
and was counseled for stress management. striae on the left buccal mucosa

Discussion
OLP is a chronic autoimmune mucocutaneous disease primarily
affecting primarily middle-aged women. An abnormal T-cell
mediated immune response is the main underlying factor which
results in basal epithelial cells to be recognized as foreign bodies
due to changes in the antigenicity of their cell surface. However,
the cause of this immune-mediated damage of basal cell layer is
still not known.[1]
The etiology of OLP appears to be multifactorial and
complicated. Ismail et al.[5] reported a list of exacerbating
factors for OLP and OLP reactions such as stress, drugs (anti-
malarial, diuretics, gold salts, antiretroviral, beta blockers,
and penicillamine), certain dental materials (dental amalgam,
composite and resin-based materials, and metals), chronic liver
disease and hepatitis C virus, genetics and tobacco chewing.
Systemic diseases seen associated with OLP includes diabetes Figure  3: Whitish lacy striae arranged in annular pattern
mellitus, hypertension, ulcerative colitis, myasthenia gravis, surrounded by pigmentation

12 Journal of Medicine, Radiology, Pathology & Surgery ● Vol. 4:1 ● Jan-Feb 2017
Erosive lichen planus: A case report Balraj, et al.

lupus erythematosus, etc. In the present case, stress seems to Conclusion

be a possible aggravating factor besides the patient being a
hypertensive and taking medications for same. Numerous controversies surrounding OLP should be
Although there are several clinical forms of OLP (reticular, restricted purely at academic levels; but as far as clinical
patch, erosive, and bullous), the most common are the reticular practice is concerned, the chances of EOLP to develop
and erosive forms. Oral lesions are more common than skin into squamous cell carcinoma (0.4-5%) justifies the need
lesions, and in few cases, the former precedes the latter.[4] The for immediate investigatory procedures followed by the
present case, however, had only oral changes and was devoid of earliest institution of appropriate treatment with a long-term
any dermatologic manifestations. monitoring of such patients. Furthermore, strategic care
In OLP, reticular and atrophic lesions usually tend to develop should be taken when counseling and educating such patients
within all erosive lesions unlike other vesiculo-erosive diseases about this chronic disease and its clinical course, so as to
such as pemphigus and pemphigoid. The latter occur as solitary avoid the build-up of excessive stress that would only worsen
erythematous lesions which are not usually associated with any the clinical picture.
white striae and pathognomonic feature being Nikolsky’s positive.
Clinical significance
This can aid in clinical differential diagnosis since erosive and
atrophic forms of OLP usually show concomitant reticular form.[6] Classic OLP is more frequently encountered in private dental
Discoid lupus erythematosus lesions show straight sharp clinics than its other variants. The rarity of the variants and
abrupt ending of striae due to which it was also considered as their atypical presentations make their timely diagnosis and
a differential diagnosis. However, its higher predilection to management more difficult in the clinical setting. Oral lesions
women of the 3-4th decade and the absence of the characteristic are chronic, rarely undergo spontaneous remission; furthermore,
“butterfly rash” helped us to exclude the same from diagnosis.[7] erosive oral lesions are difficult to palliate and can persist for
Certain cases of bullous OLP may mimic lesions of erythema 15-20 years.
multiforme, but the latter has a more acute clinical course and This case report reviews the clinical approach to an erosive
extensively involves the labial mucosa.[6] variant of OLP; wherein, the patient was educated, counseled
Erosive form of OLP has the highest malignant transformation about the chronicity of the condition and also about its high
rate when compared to the other variants. Literature with risk of malignant transformation; immediate biopsy being
evidence of previously published studies[8-10] concluded that prompted; followed by the institution of appropriate, timely
the risk of developing squamous cell carcinoma in patients with treatment.
OLP is approximately 10 times higher than that in the unaffected
general population. Therefore, clinicians should closely
observe such suspicious lesions and confirmed the diagnosis References
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Balraj, et al. Erosive lichen planus: A case report

Transformation of atypical Lichen Planus: Analysis of 32 cases.

How to cite this article: Balraj L, Nagaraj T, Nigam H, Tagore S.
Med Oral 2003;8:2-9.
Erosive lichen planus: A case report. J Med Radiol Pathol Surg
12. Edwards PC, Kelsch R. Oral lichen planus: Clinical presentation
and management. J Can Dent Assoc 2002;68:494-9. 2017;4:11-14.

14 Journal of Medicine, Radiology, Pathology & Surgery ● Vol. 4:1 ● Jan-Feb 2017