Variations in Presentations of Esophageal Involvement in Lichen Planus

doi:10.1016/j.cgh.2010.04.024

Clinical Gastroenterology and Hepatology

Volume 8, Issue 9, September 2010, Pages 777-782

https://doi.org/10.1016/j.cgh.2010.04.024 Get rights and content

Background & Aims

Lichen planus is a relatively uncommon, presumed autoimmune disease that affects middle-aged patients and is manifested in the skin, nails, and mucous membranes. Reports of esophageal involvement have been rare, despite the classification of the esophagus as a mucous membrane.

Methods

Assuming esophageal involvement might not be as rare as expected, we reviewed the Mayo Clinic Pathology Database for all cases from 2000 to the present.

Results

Twenty-seven cases were identified, with a mean age of 64 years; 25 were women. Patients presenting with esophageal lichen planus as the initial manifestation and those with a diagnosis of lichen planus involving other sites were equal in number. Many patients had received multiple dilations and reflux treatments before diagnosis. All patients presented with dysphagia. Endoscopy and radiology studies demonstrated a wide range of abnormalities, including strictures of varying length and location, small-caliber esophagus, and a mucosal appearance of sloughing, white discoloration, erythema, thickening, and superficial ulceration. Treatment regimens varied markedly, with some patients responding to topical or systemic corticosteroids.

Conclusions

Esophageal lichen planus is rare but probably more common than previously suspected. It presents with a wide range of endoscopic signs and is commonly the presenting sign of lichen planus. In evaluating middle-aged patients with strictures, particularly proximal esophageal strictures in women, physicians should consider a diagnosis of lichen planus even in the absence of extraesophageal manifestations.

Section snippets

Methods

The Mayo pathology database was searched for all patients with findings consistent with lichen planus on esophageal biopsy between 2000 and 2009. Histologic findings that were considered consistent with lichen planus were lichenoid lymphocytic infiltrate, damage to the basal layer of the epithelium, and necrotic keratinocytes (Civatte bodies). The biopsies were all reviewed by one pathologist (T.S.). The following clinical data were then extracted from the patients' charts: age, sex, type and

Demographics and Symptoms

Twenty-five patients were women, and 2 patients were men (Table 1). The age range was 50–76 years, with a median age of 64. No patients had a history or tested positive for hepatitis C virus. All 27 patients noted solid food dysphagia as their dominant symptom of esophageal disease. Two patients also complained of odynophagia. The severity was variable, with some patients having intermittent symptoms whereas others had symptoms at every meal including 2 patients who were avoiding all solid food

Discussion

This is the largest series reported on patients with symptomatic involvement of the esophagus by lichen planus. As a result, several conclusions can be drawn concerning this disease. (1) Esophageal involvement by lichen planus is rare but might be more prevalent than previously described. (2) Esophageal lichen planus is highly variable in terms of its association to extraesophageal disease and its ability to present as the initial manifestation of lichen planus. (3) There is typically a long

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We retrospectively evaluated the medical records of our patients with non-eosinophilic stricturing esophagitis for clinical, endoscopy, and pathology data. Patients were evaluated by a dermatologist. A blood immunoassay and skin biopsy were performed if needed.
Thirty-eight patients (twenty-six women) were included in the study. The median age at onset of symptoms was 56.5 years, with a median duration of symptoms of two years. Thirty-five patients presented with dysphagia at diagnosis and eighteen with weight loss. At endoscopy, a single esophageal stenosis was diagnosed in 19 patients, localized in the upper third in 22 patients. Thirty patients received endoscopic treatment (dilatation in 29/38 and local triamcinolone injection in 11/38 patients).
In 21 patients, oral, skin or vulvo-anal lesions were found on dermatological examination. Nineteen patients received systemic treatment, including corticosteroids, immunosuppressive drugs and plasmapheresis. Five patients developed esophageal squamous cell carcinoma.
The management of non-eosinophilic chronic stricturing esophagitis is challenging, because of a low contribution of esophageal biopsies and the refractory nature of the strictures. In our experience, a dermatological evaluation helped in 55% of cases to introduce a systemic treatment, leading to limit the use of endoscopic dilatation. Endoscopic follow-up is needed, considering the significant risk of esophageal squamous cell carcinoma.
Coexistence of oral lichen planus and vulvar lichen sclerosus
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Oral lichen planus (OLP) is a mucosal variant of lichen planus. Lichen sclerosus (LS) is an inflammatory disorder with a predilection for genital skin. We aimed to identify the characteristics of patients with both mucosal diagnoses.
This retrospective study included 86 women with both OLP and vulvar LS diagnosed from June 1, 1991 through November 30, 2020 at a Mayo Clinic campus in Rochester, Minnesota; Scottsdale, Arizona; or Jacksonville, Florida. Data included treatments, other cutaneous diagnoses, comorbidities, and information on patch testing and malignant transformation.
The median patient age at diagnosis was 64.5 years for OLP and 65.6 years for vulvar LS. A diagnosis of OLP before vulvar LS was most common (50.0%). The most frequently used treatment for both conditions was topical corticosteroids. Oral squamous cell carcinoma (SCC) did not develop in any patient, but vulvar SCC developed in 2 (2.3%).
OLP and vulvar LS may coexist, commonly beginning in the patient's seventh decade. Topical corticosteroids are often used to manage both conditions. The coexistence of both diseases did not seem to portend a greater malignancy risk.
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Lichen planus (LP) is a chronic, autoimmune, inflammatory disease. We believe that tympanic membrane and outer ear canal can be affected by the disease and since it is an autoimmune disease inner ear involvement may be seen. The aim of this study was to evaluate hearing functions in patients with LP. Thirty patients with LP and 28 healthy controls were involved in the study. Pure tone audiometry, tympanogram and Transient Evoked Otoacoustic Emissions tests were applied to the patients. When the airway hearing thresholds of the patient and control groups in the 125–8000 Hz frequency range were compared, statistically significant differences were found at 4000, 6000 and 8000 Hz frequencies in the right ear and at 125, 4000, 6000 and 8000 Hz frequencies in the left ear. In the LP patient group, 6 patients had sensorineural hearing loss, 3 patients had conductive hearing loss, and 2 patients had mixed hearing loss. Of the 3 patients with conductive hearing loss, 2 had cutaneous and 1 had both mucosal and cutaneous involvement. Of the patients with mixed hearing loss, 1 had cutaneous and 1 had both mucosal and cutaneous involvement. In patients with sensorineural hearing loss, 1 had mucosal, 3 had cutaneous, and 2 had both mucosal and cutaneous involvement. Sensorineural, conductive or mixed hearing loss can be observed in LP patients.
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Cancer arising in lichen planus of the esophagus (LPE) is extremely rare. We report 2 elderly female patients with LPE who developed squamous cell carcinoma. Both underwent laparoscopic ischemic gastric preconditioning followed 2 weeks later by 3-field esophagectomy. Final pathological stages were carcinoma in situ and pT3N2, respectively. No adjuvant therapy was given. The patient with in situ cancer has no evidence of recurrence at 24 months. The second patient opted to follow up locally and died 8 months later. LPE should be closely monitored for malignant degeneration. Esophagectomy should be considered when malignancy is detected.

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: Conflicts of interest The authors disclose the following: Jeffrey A. Alexander received support from Glaxo Smith Kline, Merck, and Novartis and is a consultant for Wyeth and Meritage. The remaining authors disclose no conflicts.

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Original article—alimentary tractVariations in Presentations of Esophageal Involvement in Lichen Planus

Background & Aims

Methods

Results

Conclusions

Section snippets

Methods

Demographics and Symptoms

Discussion

J Am Acad Dermatol

Gastrointest Endosc

Gastrointest Endosc

Oral Surg Oral Med Oral Pathol

Esophageal lichen planus: the Mayo Clinic experience

Dis Esophagus

Dysphagia due to pharyngeal and oesophageal lichen planus

J Laryngol Otol

Stenosing lichen planus of the esophagus (letter)

Gastroenterol Clin Biol

Lichen planus of the esophagus

Am J Dermatopathol

Lichen plan erosive stenosant de l'oesophage

Gastroenterol Clin Biol

Stenosing lichen planus of the esophagus: gastroesophageal reflux does not appear to be the cause! (letter)

Gastroenterol Clin Biol

Lichen plan plurimuqueux et atteinte oesophagienne

Sem Hop Paris

Lichen plan et stenose oesophagienne: a propos d'un cas

Ann Derm Venereol

Original article—alimentary tract
Variations in Presentations of Esophageal Involvement in Lichen Planus