Page 11 - GP Fall 2022_Neat

to appear several months later localized easting, especially hot and spicy foods. The cell carcinoma. There is approximately a
to the head, trunk, and intertriginous sites main difference between the two is that 1.5% increased risk for patients with lichen
(Figures 23-25). pemphigus is considered to be potentially planus to develop squamous cell carcino-
fatal while pemphigoid is not. They are ma in the affected areas. Although oral
both autoimmune diseases, self-attacking lichen planus was originally described in
self, however the location of the auto an- 1889, the true etiology and pathogenesis of
tibodies attacking the antigens is different. oral lichen planus remains unknown. It is
In pemphigoid, the basal cell lay separates seen in both skin and mucous membranes
from the connective tissue, the epithelium although many patients will present with
remains intact, and the separation is at the either mucous membrane or skin mani-
lamina propria. With pemphigus vulgar- festations of the disease. Patients with li-
is the body is attacking the ‘cement’ that chen planus may experience flares if they
keeps the desmosomes attached to each also have active Hepatitis C, an increase in
other in the epithelium. As the attachments stress, and specific food exposures such as
break apart, serum from the connective tomatoes, oranges, vinegar, pineapple and
tissue leaks out and the patients without seasoned dishes. Foods are not an allergic
intervention will die like burn victims die reaction, however they are an irritation.
from serum loss, electrolyte imbalance and Others may experience flares following
eventually kidney failure. Both conditions dental procedures. It may be associated
are treated with topical and systemic ste- with connective tissue disorders and some
roids as needed, along with immunosup- systemic diseases, as well as alcohol and
pressant medications. The fatality rate has tobacco abuse. It is difficult to quantify and
much improved with patients who have measure how psychological factors pro-
pemphigus vulgaris, however, due to its mote the exacerbation of oral lichen pla-
potentially fatal nature, it is imperative nus, but it is a known statistical association
that a physician also be involved with the and not purely anecdotal information.
patients’ care. Both diseases will wax and
Figures 23-25. Pemphigus vulgaris. wane, and are often associated with chang- Clinical: Oral lichen planus has specific
es in lifestyle and increased levels of stress. and clearly identifiable features, usual-
Although both diseases can present in pa- ly presenting as either the reticular or the
Age/Sex/Race: Pemphigus vulgaris is tients of any age/sex or race, both are more erosive form. The reticular form is more
seen in middle aged and elderly patients, common in women over the age of 40 with commonly referred to as Wickham striae,
predominantly female, with an Ashkenazi an Ashkenazi Jewish background. Neither which is characterized by slightly raised
Jewish or Mediterranean background. disease can be cured, therefore the best we hyperkeratotic white lacy streaks with dis-
can do for our patients is treat them palli- crete erythematous borders. This presenta-
Treatment: These patients should be man- atively. Remember that those patients with tion is different from the other forms of oral
aged by a physician as pemphigus vulgaris confirmed cases of pemphigoid need a re- lichen planus; the plaque form, the bullous
is a potentially fatal disease. In fact, before ferral to an eye doctor to prevent or treat form, and the dysplastic forms are much
the advent of medications including antibi- symblepharon. A biopsy diagnosis along less common. When the dorsal tongue is in-
otics and immunosuppressant medications, with immunofluorescent blood work will volved, the lesions tend to present as kera-
it was uniformly fatal. The main treatments provide the information needed to treat the totic plaques surrounded by slight erosions.
are palliative as it cannot be cured, includ- patient appropriately. Wickham striae typically cause no discom-
ing systemic and topical steroids along fort, nor do the keratotic areas on the dor-
with immunosuppressants as needed. To Oral Lichen Planus vs. Cheek Biting sal tongue. Patients occasionally complain
maintain their oral health, it is recommend- (Morsicatio Buccarum) of roughness in the area of hyperkeratosis
ed to gently brush with a soft toothbrush, but not of pain. Erosive lichen planus often
use nonalcoholic based mouth rinses and Oral Lichen Planus presents as thin and erythematous mucosa
have frequent dental hygiene treatments. surrounded by radiating thin Wickham’s
Ultrasonic scaling should be avoided. Etiology: Lichen planus is one of the most striations. The erosive form of oral lichen
common mucocutaneous diseases that planus is more problematic to the patient as
Comparison of Mucous Membrane presents in the oral cavity. The prevalence the erythematous atrophic mucosa is often
Pemphigoid vs. Pemphigus Vulgaris in the general population is 1% to 2%. Mi- sensitive. If the erosion is severe and the
croscopically, there is a liquifying degen- epithelium separates, it is called bullous
Pemphigus and pemphigoid often present eration of the basal cell layer with a thick
with similar findings especially in early band of lymphocytes below the affected lichen planus. It is important to confirm
manifestations of the disease. Patients re- tissues. Of concern is the predilection of the diagnosis by biopsy and immunofluo-
port sore irritated inflamed gingiva, a pos- patients with oral lichen planus, especially rescence, if necessary. The lesions should
itive Nikolsky sign and discomfort with the erosive type, to develop oral squamous be watched regularly due to the malignant
potential of oral lichen planus, especially
www.nysagd.org l Fall 2022 l GP 11