2. Introduction
 ORAL LICHEN PLANUS
Latin- Flat Algae Like
 “leichen ruber“- described by Hebra.
 "lichen planus“- Erasmus Wilson (1869)
 Wickham noted the punctuations and striae .
 Age- 30-60 years
 Females> males.
 0.5-2% of the population.
 It have premalignant potential and can progress to SCC(0.4%).
 Resolves approximately in 1 year,
 15% to 20% of cases follow a relapsing course
Kaz, R.W., Brahim, J, and Travis,W.D.oral squamous cell carcinoma arising in a patient with long-
standing lichen planus. Oral Surg Oral Med Oral Pathol 70: 282-285, 1990.
Sarah A. Gary G. Systemic Treatment of Cutaneous Lichen Planus: An Update, Cutis. 2011;87:129-134.

3.  Etiology
 Cell-mediated immunologically induced degeneration of the basal
cell layer of the epithelium.
 Immunologically induced lichenoid lesion is the common
denominator.
 Stress, diabetes, hepatitis C, trauma, and hypersensitivity to drugs
and metals
 In response to a variety of agents (eg, drugs, chemicals, metals,
and foods) “lichenoid” reactions to dental restorations,
 Mouth rinses, antibiotics, gold injections for arthritis, and
immunocompromised status such as graft-versus-host disease.

4. Associated factors
BaganJ, et al. Topical therapies for oral lichen planus management and their efficacy: a
narrative review. Current Pharmaceutical Design, 2012, 18, 5470-5480.

5. Clinical Features
 Age- 5th decade
 F>M
 any oral mucosal site, mostly buccal mucosa.
 Pain or discomfort, which interferes with function and with
quality of life.
 The prevalence rate 0.1 and 2.2%.
 The frequency of malignant transformation ranges from
0.4% to 5.3% with the highest rate noted in erythematous
and erosive lesions
Rajendran R. Oral lichen planus. J Oral Maxillofac Pathol 2005;9(1):3-5

6. Clinical Subtypes
.
 Reticular- lacelike keratotic mucosal configurations
 Atrophic - keratotic changes combined with mucosal
erythema
 Erosive - pseudomembrane- covered ulcerations combined
with keratosis and erythema
 Bullous – rare- vesiculobullous presentation combined with
reticular or erosive patterns
 Reticular
 Plaquelike
 Erosive
 Papular
 Atrophic
 Bullous
 Papular form- Minute white papules which gradually enlarge
and coalesce to form either a reticular, annular, or plaque
pattern.
Parashar P. Oral Lichen Planus. OtolaryngolClin N Am. 44 (2011) 89-107
Burkit’s oral medicine 11th edi

7. Morphology Description
Reticular
Annular
(a) Slightly elevated fine whitish lines (Wickham’s striae) lacelike
pattern or a pattern of fine radiating lines or
(b) Annular lesions- 'Ring-shaped' lesions, develop gradually
from single small pigmented spots into circular groups of
papules with clear, unaffected skin in the center.10% cases.
Atrophic
Inflamed areas of the oral mucosa covered by thinned red-
appearing epithelium.
Bullous Rare and may sometimes resemble a form of linear IgA disease.
Ulcerative/
Erosive
Complication of the atrophic process after trauma or ulceration.
Symptomatic- mild burning to severe pain.
Central area of erosion with yellowish fibrinous exudate
surrounded by erythema.
Burkit’s oral medicine 11th edi
Paul C. Edward, oral lichen planus :clinical presentation and management,2002,68(8),494-99

8. Differential diagnosis
 Leukoplakia
 Graft vs host ds
 Discoid lupus erythematosus
 Chronic candidiasis
 Mucous membrane pemphigoid
 Chronic cheek biting
 Lichenoid reaction
 Hypersensitivity mucositis
 White sponge nevus
 IgA reaction
Paul C. Edward, oral lichen planus :clinical presentation and management,2002,68(8),494-99

9. Treatment
Many patients with oral lichen planus may not have any symptoms,
in such cases there may be no need for active treatment except
for reassurance and periodic check-ups.
However, in many cases patients suffer from painful, erythematous,
erosive or bullous lesions which have a slight predilection for
transformation into oral squamous cell carcinoma. Thus, the
principal aim of treating OLP would be to resolve the painful
symptoms, the oral lesions and long-term follow-up to counter the
chances of transformation into
malignant lesions, especially for erosive and atrophic forms of
OLP, which are more prone for transformation.
G. Lodi,Current controvercies in OLP: report of an international consensus meeting,
oral surg, oral path, oral med,2005;100:164-78

10. Corticosteroids
 The efficacy of corticosteroids for treatment of lichen planus is mainly
attributed to its anti-inflammatory and immuno-suppressive. These can
be used topically, intralesionally and systemically .
 Topical corticosteroid therapy is usually the treatment of choice initially,
as it can be effectively delivered to the lesion surface with minimal
potential for systemic side effects.
 flucocinonide,- 0.05%
 clobetasol - 0.05% (Powercort cream, Clobenol cream),
 Triamcinolone acetonide - 0.1% buccal paste form (Tess, Kenacort oral
paste, Cortrima cream),

11.  These agents are either applied topically or rinsed (if in the form of
solution) 3-4 times/day after meal. Patients are advised not to eat
or drink for 30 minutes thereafter.
 Dexamethosone and betamethasone valverate. 0.05% gel,
 They are prescribed as gels, creams, ointment with orabase
(Kenalog in Orabase) or oral rinses.
 Drugs which are available in orabase formulations are preferred
because of their tenacity on the oral mucosa leading to better drug
delivery.
Carhere M, Gass E, Carranza M, et al. Systemic and topical corticosteroids treatment of
oral lichen planus. J Oral Pathol Med 2003;32(6):323-29.

12.  Intralesional corticosteroids are reserved for cases which do
not respond to topical steroids.
 10 to 20 mg of insoluble triamcinolone acetonide (Avcort
injection, Comcort injection) is diluted with 0.5 ml saline or
lidocaine 2% then injected into the lesion, which solubilize
gradually and therefore have a prolonged duration of action.
Silverman S Jr, Gorsky M, Lozda-Nur F. A prospective study of findings and management in
214 patients with oral lichen planus. Oral Surg Oral Med Oral Pathol 1991;72:665-70.

13.  Systemic corticosteroids are indicated for short period when fail to
respond to topical steroids.
 Prednisone (Wysolone) 40 to 80 mg daily for less than10 days without
tapering is advised
 hydrocortisone 20 mg tab or triamcinolone 4 mg tab orally max 50
mg/day for five days.
 If corticosteroids are used for prolonged therapy, they should not be
stopped abruptly. If done so, it can flare up the underlying disease for
which steroids were prescribed and cause acute adrenal insufficiency
because of HPA axis suppression.
Carhere M, Gass E, Carranza M, et al. Systemic and topical corticosteroids treatment of
oral lichen planus. J Oral Pathol Med 2003;32(6):323-29.

14.  combinations of more than one topical corticosteroid may be effective
Systemic steroids and immunosuppressants prescribed for more severe
cases would include:
 Dexamethasone (Decadron) elixir 0.5 mg/5 ml Disp: 320 ml
For 3 days, rinse with 1 tablespoonful (15 ml) qid and swallow. For 3
days, rinse with teaspoonful (5 ml) qid and swallow. For 3 days, rinse
with 1 teaspoonful (5 ml) qid and swallow every other time. Rinse
with 1 teaspoonful (5 ml) qid and expectorate.
Or
 Prednisone tablets 10 mg Disp: 26 tablets
Take 4 tablets in the morning for 5 days, then decrease by 1 tablet on
each successive day.
5days- 4 tab6th day 3 tab7th day 2tab8th day 1tab
Or –
Prednisone tablets 5 mg Disp: 40 tablets
Take 5 tablets in the morning for 5 days, then 5 tablets in the morning
every other day until gone.
5 days 5 tab7th, 9th, 11th day….

15. Retinoids
 Systemic and topical retinoids have been employed to treat OLP.
 Retinoids have antikeratinizing and immunomodulating effects.
 Retinoids include the natural compounds and synthetic derivatives of retinol
that exhibit vitamin A activity.
 Retinoids were synthesized by making minor structural changes.
 First generation compounds include retinol, tretinoin and isotretinoin.
 Second generation retinoids are synthetic analogs, which include etretinate
and acitretin.
 Third generation retinoids include arotinoids, which currently are in
development.

16.  As compared to systemic retinoids, topical retinoids are preferred
and generally produce good Results.
 Tretinoin is available in the form of 0.05% cream (Retino- A, Airol ).
 Isoretinoin is available as 0.05% gels (Sotret, Acno).
Buajeeb W, Kraivaphan P, Pobrurksa C. Efficacy of topical retinoic acid compared with topical flucinolone
acetonide in the treatment of oral lichen planus. Oral Surg Oral Med Oral Pathol 1994;83:21-25.

17. Cyclosporin
 Cyclosporin is a very commonly used immunosuppressive drug
which belongs to a family of cyclicpolypeptides derived from the
fungus Tolypocladium inflatum.
 It is basically used to prevent rejection in organ transplantation. It
inhibits chronic inflammatory reactions by inhibiting T-cell
activation and proliferation, also inhibits lymphokine production
and release of interleukin-2.

18.  Topical ciclosporin can be used either in the form of mouthwashes or in
the form of adhesive base.
 Patients are advised to swish and spit 5 ml of medication (l00 mg /ml)
three times daily for 8 weeks or 0.025% cyclosporin in an adhesive base
to apply four times daily, in some cases systemic cyclosporin has been
suggested.
 orally-administered formulation, (Neoral), is available as a solution and
as soft gelatin capsules (10 mg, 25 mg, 50 mg and 100 mg).
 (Immusol, Imusporin) 100 mg/ml oily solution (Katzung) and 100 mg/ml
oral rinse (Sandimmune)
 Systemic- 8mg/kg/day
Buajeeb W, Kraivaphan P, Pobrurksa C. Efficacy of topical retinoic acid compared with topical flu.
acetonide in the treatment of oral lichen planus. Oral Surg Oral Med Oral Pathol 1994;83:21-25.

19. Levamisole
Levamisole was developed in 1966 as an antihelmentic drug, but has
immunoregulating properties.
Mechanism of action of Levamisole has been found to Immunomodulate or
immunopotentiate T-cell mediated immunity.
Dose- Levamisole is administered at a dose of 50 mg three times/day for
three consecutive days per week for 4 to 6 weeks.
Levamisole (Ergamisol, Vermisol) is available as 50 mg,150 mg tab.
Lu Sy, Chen WJ, Eng HL. Dramatic response to levimisole and low dose prednisolone in
23 patients with oral lichen planus. Oral Surg Oral Med Oral Pathol 1995;80:705-09.

20. Azathioprine
 Azathioprine is a purine antimetabolite.
 It has anti-inflammatory properties and decreases antibody production.
 Azathioprine is reserved for patients who do not respond to other
treatment modalities. It can also be used in combination with
corticosteroids and cyclosporin.
 When used in combination with corticosteroids, azathioprine can
effectively enhance corticosteroid immunosuppressive activity.
 Thus, a lower dose of prednisone is required to achieve clinical efficacy
and thereby diminishing adverse effects of corticosteroids.
 Azathioprine (Imuran, Azoprin)- 50 mg tab. started at 50 mg/day and
can be escalated up to 150 mg/day.

21. Tacrolimus
 Tacrolimus is a macrolide form of immunosuppressant derived from a type
of bacterium, Strepto. tsukubaensis. It inhibits the transcription of
interluekin-2 and transduction of signal to T-lymphocyte, and thus
effectively causing immuno-suppresion.
 Its systemic use is comparable to corticosteroids but topical applications of
0.1% tacrolimus is proved to be far superior in treating of symptoms of oral
lichen planus than 0.05% clobetasol.
 Recent studies by application of tacrolimus ointment 0.1% four times daily
for 4 to 8 weeks resulted in faster resolving of symptoms in oral lichen
planus as compared to topical corticosteroid application.
 Topical- 0.1 to 0.3% (Tacroz Forte).
Corrocher G, Di Lorenzo G, Martenelli N, et al. Comparative effect of tacrolimus 0.1% ointment and
clobetasol 0.05% ointment in patients with oral lichen planus. J Clin Periodontol 2008;35:244-49.

22. Dapsone
 Dapsone should be considered in resistant cases of erosive OLP.
 It has anti-inflammatory and immune-modulatory effects.
 It is available as 5% gel (Acnesone)
25, 50 and 100 mg tab(Dapsone).
 Dose - 100 mg orally in divided doses and may be increased at the rate
of 50 mg/day per week to a maximum of 300 mg/ day.
Giovanni Lodi, et al. Current controversies in oral lichen planus: Report of an international
consensus meeting. (Part 2). Clinical management and malignant transformation. Oral Surg Oral
MedOral Pathol Oral Radiol Endod 2005;100:164-78.

23. Interferon
 Topically applied gel preparation containing human fibroblast
interferon and interferon-alpha have suggested to improve erosive
OLP. Development and exacerbation of OLP during and after IFN-
alpha therapy for HCV infection have been reported, although
systemic IFN-alpha (3-10 million IU thrice weekly) is successfully
used to treat OLP in patients with and without HCV infection.
 It is available as vials (Roferon-A) and syringes (Intafla-PF)

24. Mycophenolate Mofetil
 It is an immunosuppressant used in treatment of patients with transplants.
 It is available as 250 and 500 mg tablets (Baxmune) and 200 mg/ml
suspension (Cellcept).
Thalidomide
 It has been documented to have anti-inflammatory action in cases of auto-
immune disease
 Use of thalidomide as a regular line of treatment is not recommended,
unless all other treatment options have been exhausted. Its role in
teratogenicity has to be remembered at all times.
 Available as 100 mg capsules (Oncothal)
Dalmau J, Puig L, Roé E, Peramiquel L, Campos M, Alomar A. Successful treatment of oral erosive lichen
planus with mycophenolate mofetil. J Eur Acad Dermatol Venereol 2007;21(2):259-60.
Macario-Barrel A, Balguerie X, Joly P. Treatment of erosive oral lichen planus with thalidomide (French).
Ann Dermatol Venereol 2003;130:1109-12.

25. PUVA Therapy
 Photosensitizing psoralen drug and UVA
 radiation was introduced as a new therapy for oral mucosal lesions in
1987 by Jansen et al.
 Psoralens belong to the furocoumarin class of compounds, which are
derived from fusion of a furan with a coumarin.
 Four psoralens are used in PUVA therapy—psoralen, 5 methoxy psoralen
(Bergapten), 8-methoxypsoralen (Methoxsalen) and 4, 5, 8-trimethyl
psoralen (Trioxsalen). Ultraviolet irradiation in combination with
psoralens modulates the function of the cells of the immune system.
 Psoralen(topical or systemic sensitizer)+ UVA(320-400nm) exposure

26. Nontherapeutic Options
 Photodynamic Therapy
 Photodynamic therapy is a technique that uses a photosensitizing
compound activated at a specific wavelength of laser light to destroy the
targeted cell via strong oxidizers, which cause cellular damage, membrane
lysis and protein inactivation. It may have immunomodulatory effects and
may induce apoptosis.
 Methylene blue can be administered topically and orally and it may be a
preferred choice for superficial lesions in skin and oral cavity. The fact that
methylene blue has a strong absorption at wavelength longer than 620 nm,
where light penetration into tissue is optimal, has led to the use of
methylene blue as a promising candidate for PDT.

27. Surgery and Lasers
 Surgical excision, cryotherapy, CO2 laser and ND:YAG laser have all
been used in the treatment of OLP.
 In general, surgery is reserved to remove high-risk dysplastic areas.
 Excimer 308 nm laser is an effective choice for treatment of OLP
cases as it is well tolerated and painless when used.

28. Maintainance
 Avoidance of precipitating factors like spicy or acidic foods,
tissue trauma, and xerostomia- inducing agents.
 A "magic mouthwash" containing benadryl, kaopectate (or
carafate), and milk of magnesia as a base to which nystatin
and/or lidocaine may be added for maintenance therapy.
 When pt is not responding to corticosteroid and triamcinolone
CO2-LASER- lessens pain and burning sensation, no
recurrence upto 1 yr.
De magalhaes,, removal of OLP by CO2- LASER, Brazilian dent j.2011;22(6);522-6

29. HEPATITIS C VIRUS INFECTION AND ORAL LICHEN PLANUS
Hepatitis C Virus (HCV) may be an etiologic factor in OLP., The
characteristic band like lymphocytic infiltrate might thus be
directed toward HCV infected cells. Whether HCV infected patients
have increased risk of developing OLP or patients with OLP have
enhanced risk of developing HCV infection is yet to be answered.
The putative pathogenetic link between OLP and HCV still remains
controversial and needs a lot of prospective and interventional
studies for a better understanding

31. Sharma et al. Erosive Oral Lichen Planus and its Management: A Case
Series, J Nepal Med Assoc 2008;47(170):86-90
 Topical corticosteroids are the mainstay in treating mild to moderately
symptomatic lesions, include 0.05% betamethasone valerate gel,
0.05% fluocinonide gel, and 0.1% triamcinolone acetonide ointment.
 The prophylactic use of a 0.2% Chlorhexidine gluconate rinse may help
reduce the incidence of fungal infection during corticosteroid therapy.
 The depth of thermal damage for the CO2 laser extends from 50 to
100μm compared to 200 μm for Argon and 600 μm for the Nd: YAG
laser.19 Therefore, one can expect a lower risk with CO2 laser to the
periosteum and the underlying bone.

32.  A double blind study of 28 pt with severe oral lichen plnus treated
with etretinate(75 mg daily) or a placebo for 2 mths, showed that
the retinoid had a marked beneficial effect.
Kjell H. Hakan M. Severe oral lichen planus: treatment with an aromatic
retinoid, BJD, 2006, 23(5), 121-26

33. López J, Roselló Llabrés X, Cyclosporine A, an alternative to the oral lichen planus
erosive treatment. Bull Group Int Rech Sci Stomatol Odontol.1995;38(1-2):33-8.
 Presented a double-blind study in two groups afflicted with erosive oral
lichen planus of long evolution and resistant to other treatments.
 In the group A he used mouthwashes with a 5 ml Cyclosporine A solution
to a 10% in olive oil of 0.4 degrees of acidity for 5 minutes, tds for 8 weeks.
 In the control group he used acetonide of triamcinolone 01% in aqueous
solution.
 After 2 weeks, Patients in group A improved considerably in their
symptomatology in a 90% against a 60% in group B.

34. Neeta Misra, Efficacy of diode laser in the management of oral lichen
planus, BMJ Case Reports 2013; doi:10.1136/bcr-2012-007609
 The patient with OLP lesions was treated using diode laser (940 nm) for
the symptomatic relief of pain and burning sensation.
 The patient was assessed before, during and after the completion of the
treatment weekly. The treatment was performed for 2 months and the
patient showed complete remission of burning sensation and pain.
 The follow-up was performed for 7 months and no recurrence of
burning sensation was found.

35. According to naturalnews.com
Aloe vera
 A controlled trial published in the British Journal of Dermatology
confirmed empirical findings that aloe vera can effectively treat mouth
ulcers associated with oral lichen planus.
 Patients who were given aloe vera topical applications reported
50% improvement in symptoms and 33% of them reported that
burning pain in the mouth disappeared. Sciencedaily.com also
supports the use of aloe vera to alleviate the discomfort associated
with oral lichen planus.
 Aloe vera contains anthraquinones, chemical compounds that
promote healing and arrest pain because of their anti-inflammatory
nature.

36. Bee Propolis
 Bees use propolis, a natural resin found in young tree buds;
remetabolize it with their own nectar secretions to make a sealant to
build their hives. Bee propolis contains antimicrobial properties that
are effective in killing bacteria. Extracts of propolis can inhibit the
growth of bacteria, including Staphylococcus aureus, the cause of
deadly infections in hospital.
 It is not only effective in fighting cavities, gingivitis, periodontal
disease, and reducing plaque buildup and bad breath, but it can also
kill bacteria and bring relief to oral lichen planus sufferers.

37. Petruzzi M, Lucchese A, Topical retinoids in oral lichen planus
treatment: an overview. Dermatology. 2013;226(1):61-7.
 Reviewed Sixteen studies (280 OLP patients topically treated with
different classes of retinoids) and concluded that topical
Isotretinoin was the most frequently employed retinoid in the
treatment of OLP. Particularly keratotic form better responds than
erosive form.

38. G. Lodi,Current controvercies in OLP: report of an international
consensus meeting,oral surg, oral path, oral med,2005;100:164-78

39. €

40. 12 months)
Atrophic Topical,
flucocinonide,- 0.05%
clobetasol - 0.05%
(Powercort cream,
Clobenol cream),
Triamcinolone
acetonide - 0.1%
buccal paste form
(Tess, Kenacort oral
paste), 20-40mg
Intralesional
10 to 20 mg
triamcinolone
acetonide (Avcort inj)
+ 0.5 ml saline or
lidocaine 2%
Asymptomatic-Lycopene
retinoids
Symptomatic-
steroids
Oral prednisone
(recurrence)
Dapsone (50-150 mg
daily)
Resistant -ciclosporine
Azathioprine
Levamisole
Tacrolimus
Interferon
Not needed Avoidance of
predisposing
factors
"magic
mouthwash“
milk of magnesia
+ nystatin
and/or lidocaine.
Bullous
Erosive
Same as above Same as above PUVA
Psycho-
therapy
Surgery,
cryotherapy,
LASER
Same as above

41. Antioxidents & follow up
Symptomatic-Topical,
flucocinonide,- 0.05%
clobetasol - 0.05% (Powercort cream)
Triamcinolone acetonide - 0.1% paste
form (Tess, Kenacort oral paste),
20-40mg steroids
Oral prednisone (recurrence)
Dapsone (50-150 mg daily)
without symptoms
Intralesional
10 to 20 mg triamcinolone acetonide
(Avcort inj) + 0.5 ml saline or lidocaine 2%Systemic-
Steroids
prednisone (recurrence)
Dapsone (50-150 mg daily
Resistant –
ciclosporine
Azathioprine
Levamisole
Tacrolimus
Interferon
PUVA
Psychotherapy
Surgery, cryotherapy,
LASER
Avoidance of predisposing
factors
"magic mouthwash“ milk of
magnesia + nystatin and/or
lidocaine
Antioxidents & follow up
With symptoms