The Case of White Striations

I was asked a review some glass slides for a case last week. The patient was a 48-year-old woman who had reported to the oral surgery clinic with a complaint of painful bilateral lesions on the buccal mucosa. The lesions had been present for over 3 years. They were especially painful when the patient tried to consume something acidic or spicy. The history was waxing and waning of the lesions was not provided. 

A metal crown, placed several years ago was present adjacent to one of the lesions. The patient was hypertensive and diabetic. She was currently taking medications for both these diseases.

48-year-old woman with erosive lichen planus. The white striae can be identified at the margins of the ulcers.
Courtesy: Dr. Sidra-tul-Muntaha

The lesions were biopsied by the surgeon and submitted for histopathologic examination. The general pathologist signed this process out as chronic mucositis. The surgeon then asked me to review the slides. She told me that the striations were so prominent that it could only be lichen planus or a lichenoid reaction.

And she was right. The history, the clinical picture and the histopathologic presentation all favored a lichenoid process. Since this presentation was bilateral, lichen planus was the most appropriate diagnosis.

Lichen Planus:

Lichen planus is an autoimmune process characterized by presence of white striae. It has two major forms, reticular and erosive. Reticular lichen planus is asymptomatic and usually discovered during routine oral exams. It appears as symmetrical and bilateral, white lace-like pattern on the patient's buccal mucosa. Occasionally other sites may also be involved. It does have the ability to evolve into the more painful, erosive form. Erosive lichen planus in painful because of mucosal atrophy and ulcer formation. This type of lichen planus is associated with desquamative gingivitis.

Like all autoimmune processes, lichen planus waxes and wanes over a period of time. A flare is noted every few weeks to months.

No management is required for the reticular type.

For erosive lichen planus, potent topical steroids should be applied 4-6 times a day to control the flare. Once the lesions heal up, the patient can stop drug application until the next flare.

It is important to keep in mind that steroid application inside the mouth may lead to candidiasis. In such instances, the steroid will no longer heal the lesions and the symptoms would continue. Following confirmation of a candida infection by culture or cytology, a course of appropriate anti fungal therapy is recommended. I prefer using Clotrimazole troches for this purpose. Fifty tablets are dissolved slowly in mouth over a course of 10 days. Once the candida infection in under control, steroid application can begin again.

Note:

This patient is particularly interesting because she had a metal crown adjacent to one of the lesion, and she was using both antihypertensive and hypoglycemic drugs. All three factors have been linked to lichenoid reactions. In this case, these processes were easy to rule out because this woman's presentation was symmetric and bilateral. Lichenoid reactions are "always" asymmetric or unilateral.

A special thanks to Dr. Sidra-tul-Muntaha for sharing this case.