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LETTER TO EDITOR
Year : 2011  |  Volume : 2  |  Issue : 1  |  Page : 39-40  

Bullous oral lichen planus: An unusual variant


Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication21-Apr-2011

Correspondence Address:
Amrinder J Kanwar
Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5178.79853

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How to cite this article:
Jindal R, De D, Kanwar AJ. Bullous oral lichen planus: An unusual variant. Indian Dermatol Online J 2011;2:39-40

How to cite this URL:
Jindal R, De D, Kanwar AJ. Bullous oral lichen planus: An unusual variant. Indian Dermatol Online J [serial online] 2011 [cited 2019 Jul 15];2:39-40. Available from: http://www.idoj.in/text.asp?2011/2/1/39/79853

Sir,

A 40-year-old male patient sought dermatology consultation for recurrent fluid-filled lesions along with whitish streaks on the buccal mucosa for 15 days. He had burning sensation in the mouth causing difficulty in eating spicy food. There was no history of smoking, alcohol or drug intake. He had a history of dental filling done 3 months before the onset of lesions. The composition of dental amalgam could not be obtained. Oral examination revealed a single round tense vesicle with surrounding reticular whitish streaks [Figure 1]. Appearance of gingiva and tongue was normal. Cutaneous examination at the time of initial visit did not show any abnormality. Two weeks later, a single well-defined violaceous annular plaque of 1×1.5 cm was noticed over the glans penis. Clinical possibilities of bullous oral lichen planus and bullous pemphigoid were considered. A punch biopsy was taken from the margin of the vesicular lesion and was sent for histopathological examination. Histopathological examination with hematoxylene and eosin stain revealed parakeratosis with hypergranulosis and mild basal cell hyperplasia. Basal cells showed edema, degeneration and early separation with lymphocytic exocytosis. Upper subepithelium showed moderate lymphocytic infiltrate [Figure 2]. Overall features were consistent with bullous oral lichen planus. Hemogram, liver and renal function test as well as lipid profile were normal. Hepatitis B surface antigen and anti-Hepatitis C virus antibodies were negative. Patch test with dental filling material could not be done due to inability to procure the composition of the filling material. Treatment was started with 25 mg acitretin once a day, 16 mg methyl prednisolone once a day, 0.1% triamcinolone in orabase three times a day and chlorhexidine mouth washes. The patient had substantial clinical improvement after six weeks of therapy.
Figure 1: Single vesicle with surrounding reticular whitish streaks

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Figure 2: Parakeratosis, hypergranulosis with basal cell degeneration forming cleft and moderate mononuclear inflammatory infiltrate in dermis (H and E, ×240)

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Lichen planus is a common disease with a worldwide distribution. The incidence of oral lichen planus varies between 0.5%-2%. [1] About 30-70% of patients with skin lesions have oral involvement, while 15% present with only oral involvement. [2] Distinct clinical subtypes such as reticular, erosive, atrophic, hypertrophic and bullous oral lichen planus are well recognized. Of these, the reticular form is the commonest while bullous is the rarest with only few cases reported till date. [3] More than one clinical subtypes can coexist as in our case where both bullous and reticular forms coexisted. Presence of cutaneous lesions may be helpful in corroborating the diagnosis of oral lichen planus. In the present case only oral involvement could be appreciated at the time of initial presentation. Thus histopathological examination was undertaken to confirm the diagnosis of bullous lichen planus and to differentiate it from other oral vesicobullous diseases. Histopathological findings were consistent with lichen planus and development of cutaneous lesions subsequently substantiated our initial diagnosis. Limited information is available regarding the management of bullous oral lichen planus. Topical and oral corticosteroids form the mainstay of therapy and dapsone has been tried with variable results. [4],[5] We combined oral corticosteroids with acitretin in our patient and the results were found to be satisfactory. Dental amalgam could have precipitated the development of lesions of oral lichen planus but we could not confirm it due to the inability to perform patch test. The extreme rarity of bullous oral lichen planus warrants reporting.

 
   References Top

1.Scully C, El-Kom M. Lichen planus: Review and update on pathogenesis. J Oral Pathol 1985;14:431-58.  Back to cited text no. 1
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2.Warin RP, Crabb HS, Darling AI. Lichen planus of the mouth. BMJ 1958;1:983-4.  Back to cited text no. 2
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3.Unsal B, Gultekin SE, Bal E, Tokman B. Bullous oral lichen planus: Report of two cases. Chin Med J (Engl) 2003;116:1594-5.  Back to cited text no. 3
    
4.Lang PG. Sulfones and sulfonamides in dermatology today. J Am Acad Dermatol 1979;1:479-92.  Back to cited text no. 4
    
5.McCreary CE, McCartan BE. Clinical management of oral lichen planus. Br J Oral Maxillofac Surg 1999;37:338-43.  Back to cited text no. 5
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