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****** DATA-MÉDICOS *********

EL LIQUEN PLANO / THE LICHEN PLANUS

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***** DERMAGIC-EXPRESS No 3 ****

****** 16 OCTUBRE DE 1.998 ******* 

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EDITORIAL ESPAÑOL:

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Saludos amigos Dermágicos, tal como les comente ayer, les traigo hoy unos

articulos interesantes sobre el liquen plano.

Saludos a todos...

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DERMAGIC/EXPRESS(3)

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E L  L I Q U E N P L A N O / LICHEN PLANUS

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REFERENCIA: 1: Asociacion con vacunación contra hepatitis B

REFERENCIA: 2: Asociación con Hepatitis C

REFERENCIA: 3: Respuesta a tratamiento con LEVAMIZOL y PREDNISOLONA

REFERENCIA: 4: Respuesta a tratamiento con Heparina. 

REFERENCIA: 5: Asociación con VPH en lesiones orales

REFERENCIA: 6: Respuesta a tratamiento con Interferon.

REFERENCIA: 7: Respuesta a tratamiento con glycyrrhizin (LICORICE), esta

referencia va cerrada pues la base de datos no ofreció mas. La monté, pues

el LICORICE planta de origen CHINO esta siendo USADA para enfermedades

virales, y se esta hablando de asociación de LP con Hepatitis.

ACTUALIZACION: The skin letter therapy: 

STUART MADDIN JULIO 1998: ORAL LICHEN PLANUS

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1.) [Lichen planus and vaccination against hepatitis B]

TO: Lichen plan et vaccination anti-hepatite B.

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AU: Lefort-A; Dachary-D; Vergier-B; Boiron-G

AD: Service d'Anatomopathologie, Hopital du Haut Leveque, Pessac.

SO: Ann-Dermatol-Venereol. 1995; 122(10): 701-3

ISSN: 0151-9638

PY: 1995

LA: FRENCH; NON-ENGLISH

CP: FRANCE

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.

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2.) TI: [Lichen planus and hepatitis C virus. Apropos of 5 new cases]

TO: Lichen plan et virus de l'hepatite C. A propos de 5 nouveaux cas.

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AU: Hyrailles-V; Peyron-N; Blanc-P; Mark-Y; Meunier-L; Meynadier-J;

Larrey-D; Michel-H

AD: Service d'Hepato-Gastroenterologie, Hopital Saint-Eloi, Montpellier.

SO: Gastroenterol-Clin-Biol. 1995 Oct; 19(10): 833-6

ISSN: 0399-8320

PY: 1995

LA: FRENCH; NON-ENGLISH

CP: FRANCE

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.

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TI: 3.) Dramatic response to levamisole and low-dose prednisolone in 23

patients with oral lichen planus: a 6-year prospective follow-up study.

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AU: Lu-SY; Chen-WJ; Eng-HL

AD: Department of Dentistry, Ghang Gung Memorial Hospital, Kaohsiung,

Taiwan, Republic of China.

SO: Oral-Surg-Oral-Med-Oral-Pathol-Oral-Radiol-Endod. 1995 Dec; 80(6): 705-9

ISSN: 1079-2104

PY: 1995

LA: ENGLISH

CP: UNITED-STATES

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

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4.) Low-dose low-molecular-weight heparin (enoxaparin) is beneficial in

lichen planus: a preliminary report 

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Emmilia Hodak, MD,a Gil Yosipovitch, MD,a Michael David, MD,a Arieh Ingber,

MD,b

Liran Chorev, MD,b Ofer Lider, PhD,c Leora Cahalon, PhD,c and Irun R.

Cohen, MDc 

Petah Tikva, Tel Aviv, Jerusalem, and Rehovot, Israel 

Background: Low-dose heparin devoid of anticoagulant activity inhibits

T-lymphocyte heparanase activity, which is crucial in T-cell migration to

target tissues. 

Objective: The purpose of this study was to assess the efficacy of low-dose

enoxaparin (Clexane), a low-molecular-weight heparin, as monotherapy in

lichen planus. 

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.) 

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5.) TI: [Detection of human papillomavirus (HVP)-DNA in oral manifestation

of lichen planus]

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TO: Nachweis humaner Papillomavirus (HPV)-DNA bei oraler Manifestation von

Lichen planus.

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AU: Vesper-M; Riethdorf-S; Christoph-E; Ruthke-A; Schmelzle-R; Loning-T

AD: Abteilung fur Mund-, Kiefer- und Gesichtschirurgie,

Universitatskrankenhaus Eppendorf.

SO: Mund-Kiefer-Gesichtschir. 1997 May; 1(3): 146-9

ISSN: 1432-9417

PY: 1997

LA: GERMAN; NON-ENGLISH

CP: GERMANY

AB: Human papilloma viruses (HPV) can be detected in different epithelia

with the help of the polymerase chain reaction (PCR). The role of HPV in

the development of anogenital cancers has been intensively studied, and

current evidence shows that most cervical cancers are associated with

so-called high risk HPV types (e.g. HPV 16 and 18). HPV-infections can also

be demonstrated in oral premalignant lesions and squamous cell carcinomas.

Depending on the sensitivity of the detection method, 40-67% of

leukoplakias, 2.5-76% of squamous cell carcinomas and 0-87% of cases of

lichen planus were described to be infected with HPV 16 or 18. Whether

lichen planus can be considered as a premalignant lesion is still

controversial. By the use of PCR and hybridization we found infections with

the high risk HPV types 16, 18 and 31 in 42% (3/7) of the patients with

lichen planus. 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.

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6.) TI: Successful treatment of generalized lichen planus with recombinant

interferon alfa-2b.

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AU: Hildebrand-A; Kolde-G; Luger-TA; Schwarz-T

AD: Department of Dermatology, University of Munster, Germany.

SO: J-Am-Acad-Dermatol. 1995 Nov; 33(5 Pt 2): 880-3

ISSN: 0190-9622

PY: 1995

LA: ENGLISH

CP: UNITED-STATES

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.

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7.) TI: A case of oral lichen planus with chronic hepatitis C successfully

treated by 

glycyrrhizin

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AU: Nagao-Y; Sata-M; Tanikawa-K; Kameyama-T

SO: Kansenshogaku-Zasshi. 1995 Aug; 69(8): 940-4

ISSN: 0387-5911

LA: ENGLISH

AN: 96083310

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8.) STUART MADDIN SKIN LETTER THERAPY JULIO 1.998

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Oral Lichen Planus: Treatment Options

Estimates of the percentage of patients with cutaneous lichen

planus (LP)

who also have oral LP vary from somewhere between a third and a

half1-3,

to as high as 70%4 and even higher when the cutaneous lesions are

of long

duration.4 Some 251-85%2-4 of patients present with only oral LP.

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

According to European reports hepatic disease does play a role in LP,

its role

seems to be less important in North America.1,2 Nevertheless, it is

reasonable to

obtain pertinent laboratory evidence on newly diagnosed patients,

especially

those with erosive disease.1,3

////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 

The 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 

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References

1.Boyd AS. Personal communication March, 1997. 

2.Rogers RS. Personal communication May, 1997. 

3.Eisen D. Personal communications March, 1997 and June, 1998. 

4.Conklin RJ. Personal communication March, 1997 and June 1998. 

5.Chosidow O, Cribier B. Treatment of lichen planus: what is the

right

choice. Med & Surg Dermatol 1998; 5: 49-52 

6.Miles DA, Howard MM. Diagnosis and management of oral lichen

planus. Dermatol Clin 1996; 14: 281-290. 

7.Arndt KA. Lichen planus. In: Fitzpatrick TB, Eisen AZ, Wolff K

et al,

eds. Dermatology in General Medicine. New York: McGraw-Hill,

1993. 

8.Maddin WS, Editor 

9.Becherest PA, Bussel A, Chosidow O et al. Extracorporeal

photochemotherapy for chronic erosive lichen planus. Lancet

1998; 351:

805. 

10.Hodak E, Yosipovitch G, David M et al. J Am Acad Dermatol 1998;

38: 564-8. 

Therapy for oral lichen planus

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First line

topical

corticosteroids

Good safety & efficacy, low cost4 used on

almost all patients.3,4

topical retinoids

Of value when combined with topical

corticosteroids in conditions such as LP of

the gingiva.3

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Second line

acitretin

May be first choice in severe, resistant

disease.8

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Other

dapsone,

hydroxychloroquine

oral corticosteroids

and

immunosuppressives

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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

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Investigational

(results need

confirmation and

these two new

treatment

approaches need

further study)

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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DATA-MÉDICOS/DERMAGIC-EXPRESS No (3) 16/10/98 DR. JOSE LAPENTA R. 

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Produced by Dr. José Lapenta R. Dermatologist
Venezuela 1.998-2.024

Producido por Dr. José Lapenta R. Dermatólogo Venezuela 1.998-2.0024

Tlf: 0414-2976087 - 04127766810