White and Red Lesions: Lichen & Lupus PDF

White and Red lesions Dr. Amira Abdelwhab Lecturer of Oral Medicine, Diagnosis and Periodontology  Infectious Other Premalignant Etiologic Classification Reactive of red a...

White and Red lesions Dr. Amira Abdelwhab Lecturer of Oral Medicine, Diagnosis and Periodontology  Infectious Other Premalignant Etiologic Classification Reactive of red and Immuno white lesions pathologic Toxic Allergic ORAL LICHEN PLANUS  Definition Oral Lichen Planus (OLP) is a chronic inflammatory disease in which basal cell damage produce mucocutaneous lesions of various types.  Etiology We dont know why this pt particularly is affected,and his body I- Idiopathic lichen planus: produced antibodies to destroy the basal cell ,it may be associated with stress Cell mediated immunologic reaction induces the degeneration of basal cell layer in the following sequences:-. Grinspan syndrome The association between these disorders may be related to the common etiologic factor they share together which is emotional stress.  Clinical Features Site: 20% of patients with oral lichen planus will also GR: the oral lesions appeare before skin lesions ?? have skin lesions Cuz the intracellular junction in oral mucosa is weakest than that in skin so it gets affected quicker than skin The rest have oral only or skin only Sex: F >> M Its not a obligatory age, it can come at any age but rarely,and most commonly in 40years, Age : 5th decade. It is a diagnostic feature btw lichen planus and lupes erythramatous Duration & course: the lesion lasts for 8-15 y and characterized by remission and exacerbation. Disease under controll  Clinical Features Exacerpation Skin lesion: Site: flexor aspect of extremities. Features (5 ps) : Purple, polygonal, pruritic papules and plaques  The color of the lesion is pink, well-developed lesions are violaceous. Older and resolving lesions are hyperpigmented (brown). On the surface of the lesion white streaks are present (wickham’s striae).  The development of new lesion following trauma as scratching is termed Kobner’s phenomena which is characteristic for the disease. The skin lesion resolves within 1-2 years, most commonly leaving hyperpigmentation Oral lesion: Site: the most common site includes the buccal mucosa (bilaterally), followed by the tongue, lips, gingiva. Types: 1- Papular form No pain and doesn't need TTT 2- Bullous erosive form most painfull case and needs TTT,cuz it have complete loss of epithelium 3- Atrophic form Painful and need ttt 1- Papular form: , Development of pinhead sized white keratotic lesions (papules) Papules mas be discrete or arranged in various clinical patterns such as linear, reticular, annular or plaque like configuration  , Plaque pattern is manifested as white raised thick patches that may be easily mistaken leukoplakia. It is multifocal Wickham’s striae are seen radiating from periphery of the lesion and are accentuated on stretching Chief complaint: no complain or patient may complain of roughness 2. Bullous erosive form: Appears as vesicle or bullae that rupture resulting in chronic irregular ulcer. Bullous erosive form represent the severe form of the disease when extensive degeneration of the basal layer of epithelium causes a separation of the epithelium from the underlying connective tissue 3- Atrophic form It appears as diffused, erythematous patches. When the lesion is subjected to trauma erosive areas may occur.  Atrophic lichen planus may be seen on the dorsum of the tongue resulting in atrophy of filiform and fungiform papillae. Symptoms ranged from mild burning to severe pain.  Wickham’s striae are seen radiating from periphery of all types of OLP and are accentuated on stretching  Bullous erosive and atrophic lichen planus involving the gingiva results in desquamative gingivitis a condition characterized by bright red edematous patches that may involve the full width of the attached gingiva Desquamative gingivitis is seen in: pemphigus vulgaris mucous membrane pempigoid Symptoms: Papular form is associated with intact surface epithelium and usually asymptomatic Bullous erosive and atrophic are associated with destruction of surface epithelium and are painful lesion. More than one form can be seen in one patient.  Diagnosis Clinical Laboratory History examination investigation  Diagnosis Case history -Remission and exacerbation. -Long duration (chronic nature) -Psychological stress (may be one of etiologic factors)  Skin lesions facilitate the diagnosis cuz it is similar to lups Clinical examination: Oral:bilateral papules,atrophy, - Skin and oral involvement???????????? - wickham’s striae. Laboratory investigation: biopsy. Fate: malignant transformation of bullous erosive and atrophic lichen planus had been reported in alcoholics and smokers.  Differential Diagnosis Lichenoid lesions (eg, drug-induced lesions, and graft- versus-host reaction) Remove the cuase, it will disappears Erythema multiforme, Lupus erythematosus Leukoplakia Squamous cell carcinoma Candidiasisregression of lesion by antifungal in one week  Treatment Patient Medical education treatment Corticosteroids Antifungals Tranquilizers Dapsone, retenoids  1) Patient education: the patient must be aware about the course of the disease (remission and excerbation). 2) Only symptomatic lesions as atrophic and bullous erosive type require treatment. The first drug of choice is corticosteroids (available in 3 forms: Topical intralesional injection systemic Topical:candidal infection only Systemic corticosteroids : make immunusupression,hyperglicemia,hypertension and osteoporosis , so it cant give systemic to pt with this diseases.  a) Topical steroid therapy includes: - Hydrocortisone hemisuccinate lozenges. - Triamcinolone ointment (kenalog orabase). Base that resist washing by saliva ,to set in pt mouth as long as it can - Triamcinolone mouthrinse. Start by the weakest preparation, e.g. hydrocotisone then if no response proceed to the stronger e.g. triamcinolone. Topical steroid is prescribed 4 times daily (once after each meal and once at bed time). It can be applied by cotton swabs or gauze pads impregnated with steroid  inject inside the lesion , it is more effective than topical,with no side effects ,but mor liable to be used in caces of single lesion to avoid multiple punches of the pt b) Intralesional steroid injection: By triamcinolone acetonide Three injections are given at interval of one week. Local anaesthea is given then inject triamcinolone around the lesion c)Systemic steroids: has to be given systemically with great care owing to its wide range of side effects. prednisone 40 mg for 7 days then 10-20 mg every day and other for other 2 weeks Low dose systemic steroid combined with non steroidal anti-inflammatory dugs in pt. contraindicated for high doses (10-20mg prednisone plus 1000mgNSAD/ day in divided doses( ibuprofen) for two weeks). 3. Antifungal drugs: Antifungal drug is used for one week if the patient is on steroid therapy for 4 weeks?????????????? (Daktaren oral gel 4 times daily ) 4.Tranquilizers (5 to 10 mg Valium or Librium) Lichenoid reaction  In lichenoid reactions the clinical and microscopic changes are consistent with lichen planus but: a. When the offending agent or antigens is removed the signs and symptoms are reversed in lichenoid. b. Perivascular eosinophils are detected in lichenoid reaction. Examples for offending agent or antigens: Drugs Amalgam restoration Graft-versus-Host Disease (GVHD) it is seen in patients who receive bone marrow transplantation. The cause of epithelial cell death is the donor T-lymphocytes. Systemic lupus erythematosus Lupus erythematosus It affects alot of body organs ,thats why it is a dangerous disease Systemic LE Discoid LE Subacute cutaneous LE Discoid lupus erythematosus (DLE)  Definition It is the least aggressive form of the disease that involves the skin and oral mucous membrane only.  Clinical features Age: predominantly in the 3rd and 4th decade Sex: F >>> M. Site : skin and oral mucosa Skin lesion: Site: sun exposed areas as face, scalp and extremities. Face: Butterfly rash: typical cutaneous lesions appear as red scaly patches on the malar region and bridge of the nose.  Cutaneous lesions are slightly elevated red macules covered with adherent scales When scales are removed, they reveal “carpet tack” due to follicular plugging (extension of keratin into the pilo-sebaceous ducts).  Follicular keratotic plug Oral lesion Classical DLE lesion has been described as alternating red (atrophic), white (keratotic) red (telangiectatic) zones  Tongue atrophy Margins of oral lesions may reveal fine white stria (wickham)??????????? D.D. Oral mucosal lesions of DLE resemble reticular or atrophic lichen planus. However, in DLE the lesion is Asymmetric peripheral striae are less prominent.  Development of squamous cell carcinoma has been described in lesions of DLE involving the vermilion border of the lip  Appearance of ulcers 4:oral lesions appear may indicate the before skin,so the early transformation of tge discovering of the oral disease from discoid lesion can give better lupes into systemic ,and prognosis cuz of early it must be diagnosed discover of the disease early to prevent its impacte on body organs Patients with oral DLE should be followed up yearly ???????????? 1. Early diagnosis of cutaneous lesions because early skin lesions respond better to treatment 2. Occurrence of oral ulceration is of clinical significance “ it may indicate the presence of latter development of SLE” 3:to prevent the transformation into sqamus cell carcinoma  Differential diagnosis Oral lichen planus Oral candidiasis (erythematous candidosis) ErythroplakiaDiscoid:butterfly. Rash on face and wichhams straia Squamous cell carcinoma  Treatment Topical steroids are used for oral and skin lesion. Systemic lupus erythematosus  Definition Systemic lupus erythematosus (SLE) is an autoimmune disease of unknown etiology characterized by multisystem involvement with varied clinical presentation  Immunologic Etiology Hormonal SLE Genetic Infection Clinical features Skin lesion Alopecia Butterfly rash Photosensitive rashes Raynaud’s phenomenon Skin lesion Raynaud’s phenomenon: cyanosis and tingling of toes and fingers on exposure to cold due to vasospasm. Renal manifestations: Glomerular destruction. Cuz in dyalasis day they take heparin "anticoaglant" and it remains in the body for 6 h Drug prescription Hemodialysis should receive dental treatment on non dialysis days????????? Pt should take penicillin before any procedure that involves breeding ,and if the pt is allergic to pencillin ,give clindamycin or arithromycin Cardiac manifestations Libman sacks Pancarditis: endocarditis: circulating pericarditis, myocarditis immune complex may and endocarditis. damage heart valve, as a result fibrin and platelets deposit at site of damage & act as nidus of bacterial colonization???????????? Neurological manifestations: Psychoses &seizures. Musculo-skeletal manifestations Arthritis Hematologic manifestations:- Leucopenia, anemia & thrombocytopenia  Infection Patients with SLE are at a risk of infection because of : The administration of immuno-suppression neutropenia.  Hematologic abnormality Prior to any extensive dental procedures pre-operative complete blood count ?????????????????. PT &APTT assessment can screen for defective coagulation. Oral manifestations The oral lesions in SLE are similar to DLE but with: Less keratinization. More ulceration  Histological features Hyperkeratosis with keratotic plugs. Liquifactive degeneration of the basal cell layer. Vasculitis and perivascular lymphocytic accumulation. Collagen destruction. Diagnosis: 1- Case history??????????????????? 2- Clinical examination??????????????? 3- laboratory investigations????????????? Biopsy Detection of ANA in serum LE cell test pancytopenia American college of rheumatology classification criteria for SLE Diagnosis of SLE requires the presence of four or more of the following criteria 1. Malar rash 7. Renal disorders 2. Discoid rash 8. Neurologic 3. Photosenstivity 9. Hematologic 4. Oral ulcers 10. Immunologic (+LE test & anti-smith antbody) 5. Arthritis 11. Positive antinuclear 6. Serositis (pleuritis, antibody (ANA) pericarditis )  Treatment Symptomatic oral lesions can be treated with : high potency topical corticosteroids (clobetasol in orabase 4 times daily) intra- lesional steroids injections (by triamcinolone).  Adrenal suppressio Infection n Hematologi c Cardiac abnormaliti disease es Exacerbation Renal by drugs or disease surgery  Patients receiving daily corticosteroids (≥ 20 mg) for more than 2 weeks: treated as if they were adrenally suppressed (dose will need to be doubled on the day of treatment)