BY

DR. IMAN METWALY

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 White lesions

Etiological classification
Hereditary Neoplastic
Squamous cell
1-Leukodema carcinoma
2-White spongy nevus
Infective Idiopathic
leukoplakia
1-Candidiasis
Reactive
2-Hairy leukoplakia
1-Frictional keratosis
Dermatological
2-Chemical
1-Lichen planus
3-Thermal
2-Lupus Erythematosus

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 4-Dermatologic conditions
Lichen planus
Definition :
A chronic mucocutaneous diseases of unknown cause

Etiology & pathogenesis

Although the cause of lichen planus is unknown , it is considered to be an

immunologically mediated process

It is characterized by an intense T-cell infiltrate { CD4 & CD8} cells localized to

the epithelium-connective tissue interface

The disease mechanism involves several steps that could be described as follows:
1. An initiating factor\ event
2. Focal release & up regulation of cytokines & vascular adhesion molecules
3. Recruitment & retention of T- lymphocytes in the submucosa {lymphocytic
band} follows
4. The basal cells undergo apoptosis & liquefaction degeneration

Clinical features

1. Age : {middle age}

2. Sex : females more in menopausal women
3. Site : buccal mucosa in the great majority of cases
4. Bilateral
5. Wide spectrum of clinical manifestation
Clinical types : a combination of these types may be seen in one case
6. Exacerbation & remission of the lesions is characteristic of lichen
planus{waxing & waning}

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Clinical types of lichen planus listed in order of frequency
of involvement of the oral mucosa

1-Reticular form :
1. The most common type
2. Characterized by numerous interlacing white keratotic lines or striae
{wickham's striae} that produce an annular or lacy pattern
3. It is usually bilateral
4. Site : mostly the posterior buccal mucosa
5. Not painfull {no symptoms }

2-Plaque type :
1. White plaque resemble leukoplakia clinically
2. Has a multifocal distribution
3. Site : primarily the dorsum of the tongue & the buccal mucosa

3-Atrophic type
1. Diffuse red patches { resembling erythroplakia }
with fine white striae {i.e. in conjunction with reticular form}
2. Site : the attached gingiva frequently involved, often in four quadrants ,in
conjunction with reticular or erosive variants
3. Symptoms : Burning , sensitivity & generalized discomfort

4-Erosive form
1. Erythematous areas with central ulceration
2. A fibrinous plaque or pseudomembrane covers the ulcer
3. The periphery of the lesion is bordered by fine white radiating striae
4. Painful
5. Often involving the four quadrant

N.B. when confined to the gingiva, it mimics ''desquamated gingivitis''

5-Bullous type
1. Bullae are short lived {rarely seen}
2. On rupturing they leave a painful ulcer

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 Skin lesions

1. Purple polygonal papules

2. Fine lace like network lines
3. Site : on the flexor surfaces of the extremeties
4. The lesions itch & hurt the patient when he scratches them

Grinspan's syndrome: lichen planus associated with diabetes mellitus &

hypertension

Histopathology
Characteristic but not specific {seen in other conditions such as lichenoid drug
reaction ,lupus erythematosus}

1. Varying degrees of orthokeratosis & parakeratosis on the surface epithelium

2. Variable thickness of the spinous layer { may be atrophic or acanthotic

depending on whether the specimen is erosive or reticular lesion}

3. The rete ridges may be absent or hyperplastic{occasionally a saw tooth

pattern is seen }

4. Liquefaction degeneration of the basal cell layer

Normal basal
cells

5. Civatte bodies : discrete eosinophilic ovoid bodies representing the apoptotic

keratinocytes at the basal zone

6. An intense bandlike infiltrate of predominantly T

lymphocytes , lying just beneath the epithelium – connective tissue junction
known as: {subepithelial lymphocytic band}

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Differential diagnosis

I-Erosive or atrophic lichen planus affecting the attached gingiva must be

differentiated from :
1. Desquamative gingivitis ,
2. lupus erythematosus,
3. Candidiasis
4. Contact hypersensitivity

2-plaque-like lesion must be differentiated from:

1. Idiopathic leukoplakia
2. Squamous cell carcinoma

3-Other diseases with a multifocal bilateral presentation that should be included in

the differential diagnosis are :
1. Lupus erythematosus
2. Cheek chewing
3. White spongy nevus
4. Chronic candidiasis

N.B.

Ulcer :is the loss of continuity of the surface epithelium

Erosion : is the superficial loss of the surface epithelium
Vesicle : is a small fluid filled swelling
Bulla : is a large fluid filled swelling
Plaque :solid raised lesions that are over 1cm in diameter
Papule :solid raised lesions that are less 1cm in diameter

A combination of these lesions may be seen in one case

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