Oral lichen planus and oral lichenoid lesions:: diagnostic and therapeutic considerations

Lichen planus is a chronic systemic disease of established immune-mediated pathogenesis. The disease commonly affects the oral mucosa, and oral lesions often occur in the absence of skin lesions. The clinical features of oral lichen planus (OLP) alone may be sufficiently diagnostic. A biopsy should be considered when the disease does not present with its typical manifestations or when there is concern of dysplasia or malignancy. Several therapeutic approaches have been investigated for the treatment of OLP. Among these are corticosteroids, retinoids, cyclosporine, phototherapy, and other treatment modalities. A systematic review of clinical trials showed that topical corticosteroids are often effective in the management of symptomatic oral lichen planus. Systemic corticosteroids should be considered for severe widespread OLP. Because of the ongoing controversy in the literature about the possible premalignant character of OLP, periodic follow-up is recommended. There is a spectrum of oral lichen planus-like ("lichenoid") lesions, that includes lichenoid contact lesions, lichenoid drug reactions and lichenoid lesions of graft-versus-host disease. These lesions may occasionally be difficult to diagnose properly. Management of oral lichenoid lesions depends on the suspected cause. In the approach to oral lichenoid contact lesions, the value of patch testing remains controversial. Confirmation of the diagnosis of an oral lichenoid drug reaction may be difficult, since empiric withdrawal of the suspected drug and/or its substitution by an alternative agent may be complicated. Oral lichenoid lesions of graft-versus- host disease (OLL-GVHD) are recognized to have an association with malignancy. Local therapy for these lesions rests in topical agents, predominantly corticosteroids. There is an ongoing controversy in the literature as to whether OLP is associated with an increased risk of malignant transformation. Nevertheless, monitoring is recommended at least annually or whenever changes in signs and/or symptoms occur.