Abstract
The lichen planus (LP) is an inflammatory and immune-mediated disorder
that can affect the hair, mucous membranes, nails, and skin. Lichen
planus rarely affects the lips. When it affects the lip presents as
radiated streaks, lace‑like papules, and erosions. There is no report of
lip LP presenting as Hypertrophic plaque.
Here we report interesting and rare clinical presentations of LP in a
45‑year‑old male patient that presented with a verrucous hyperkeratotic
plaque on the lower lip mimicking Squamous Cell Carcinoma. However, oral
examination revealed, reticulated white patches on the bilateral buccal
mucosa, and a biopsy of the lip lesion revealed lichenoid dermatitis
which led to the diagnosis of hypertrophic lichen planus.
Familiarity with the different clinical presentations of LP and its
variants is essential for prompt diagnosis and effective treatment.
Introduction
The lichen planus (LP) is an inflammatory and immune-mediated disorder
that can affect the hair, mucous membranes, nails, and
skin.1, 2 Oral lichen planus (OLP) is a common
presentation of lichen planus that can occur alone, or accompanied by
cutaneous or other mucosal manifestations.1 OLP
presents as white striations, white plaques, erythema,erosions or
vesicles affecting predominantly the buccal mucosae, tongue, and
gingivae.1
Lichen planus rarely affects the lips.3 Lip
involvement can occur isolated or with cutaneous or oral lesions.
Clinical features include radiated streaks, lace‑like papules, and
erosions.4 There is no report of Hypertrophic type on
the lip. Here we reported a rare case of oral lichen planus presenting
as verrucous plaque arising on the lower lip and as far as we know, this
is the first reported case.
Case Presentation
A 45 years old man with no specific past medical history presented with
a verrucous painless lesion on the midline of his lower lip for 3
months. The patient was not a smoker and also denied using tobacco or
alcohol. His drug history was unremarkable and no new medication was
started during this period of time.
On examination hyperkeratotic, verrucous plaques with peripheral
hyperpigmentation on the lower lip was evident.(figure 1,a) The upper
lip was uninvolved. Intraoral examination revealed white, reticulated
patches on the bilateral buccal mucosa (figure 1,b). A complete
examination of the skin, nail, and other mucous membranes was normal.
Punch biopsy of the lesion revealed parakeratotic hyperkeratosis with an
inflammatory infiltrates predominantly composed of lymphocytes along the
dermal-epidermal junction. There were some apoptotic keratinocytes, but
no evidence of keratinocyte dysplasia or squamous cell carcinoma (SCC)
was seen (figure 2,a,b). These features were considered to be those of
lichenoid dermatitis and most consistent with lichen planus.
The patient was prescribed topical tacrolimus 0.1% and clobetasol
ointment be applied locally twice a day. He was also treated with
intralesional triamcinolone (10mg/ml) monthly for 3 months.
There was considerable healing in the lip lesion during the follow‑up
period (figure 3). However, 2 months later recurrence was noted in the
same site then oral prednisolone (20mg per day ) and mycophenolate
mofetile (1g twice a day) were added to the previous treatment.
Discussion
hypertrophic lichen planus (HLP) is a variant of LP, that typically
presents with hyperkeratotic papules, plaques, and nodules on the lower
extremities.5 Hypertrophic lichen planus can also
affect the upper extremities and trunk, or it can also cause generalized
lesions.6 hypertrophic lichen planus on the lip has
not been previously reported.
Lip involvement in lichen planus is quite rare.3 lip
lesions are more commonly observed in conjunction with cutaneous and/or
oral LP but rarely occur isolated. Typical presentation includes an
erythematous patch with white radiated peripheral streaks, other
Clinical picture includes lacelike papules, and
erosions.3-5
The clinical presentation of our patient’s lip lesions as hyperkeratotic
plaque mimicked those of actinic cheilitis, SCC, chronic HSV verrocus
ulceration, pemphigus vegetan, and discoid lupus erythematous(DLE )
while reticulated patches on the bilateral buccal mucosa on oral
examination and pathologic findings were indicating of true diagnose of
lp.
Histopathological features of lip lichen planus are the same as
cutaneous or mucosal LP.7 Characteristic Histological
findings of lichen planus include acanthosis, parakeratosis,
hypergranulosis, as well as hydropic degeneration of the basal layer,
and lymphocytic infiltration at the dermo-epidermal junction in a band
like manner.7The Presence of numerous Degenerative
keratinocytes, known as colloid or Civatte bodies, in the papillary
dermis and the lower epidermis is a frequent finding in lichen planus.7
Treatment of hypertrophic LP lesions is similar to other LP
variants,2 topical, intralesional, or oral
corticosteroids are the first-line treatments. For those patients who do
not respond to corticosteroid therapy, Successful treatment has been
shown with mycophenolate mofetil, acitretin, cyclosporine, and biologics
(adalimumab, alefacept, efalizumab). 2
hypertrophic LP is a potentially malignant condition. Malignant
transformation of hypertrophic LP to squamous cell carcinoma (SCC) has
been documented in studies8; then in such cases,
long-term follow-ups are required.