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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 3  |  Issue : 2  |  Page : 96-101

A clinicopathologic study of lichen planus at a tertiary health care centre in south India


Department of Dermatology, Sri Ramachandra University, Porur, Chennai, Tamil Nadu, India

Date of Web Publication27-Dec-2016

Correspondence Address:
Dr. Aditya Kumar Bubna
Assistant Professor, Department of Dermatology, Sri Ramachandra University, Porur, Chennai 600 116, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2349-5847.196301

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  Abstract 

Background: Lichen planus (LP) is a unique inflammatory papulosquamous disorder that affects the skin, hair, nail and mucous membranes, and is associated with a relapsing and remitting course.
Aim: To study the clinicopathological profile in patients diagnosed with LP.
Methods: A cross-sectional prospective study of 100 freshly diagnosed cases of LP over a period of 1 year, wherein following patient enrolment, they underwent a thorough clinical evaluation followed by a biopsy, that was carefully studied and evaluated.
Results: A male preponderance (60%) was observed. Majority of the patients were in the 21–40 years age group (60%). Pruritus was witnessed in 84% of the patients. The morphological types of cutaneous LP encountered were classical (58.9%), hypertrophic (28.4%), linear (4.2%), lichen planopilaris (LPP) (4.2%), bullous (2.1%) and LP pigmentosus (2.1%). Out of the 42 patients with oral LP, reticulate type was present in 85.7% patients and erosive variant in the remaining 14.3%. Spotted hypergranulosis was a finding seen in 100% of the cutaneous biopsies taken. Hyperkeratosis was identified in 92.6%, pigmentary incontinence in 93.7% and subepidermal band like lymphocytic infiltrate in 92.6%. In none of the patients of LPP were the characteristic microscopic findings identifiable. In oral mucosal biopsies, dysplastic changes were evident in 50% of the participants.
Conclusion: LP is a disorder more common in males usually manifesting in the 3rd to 4th decade of life, with the classical type of cutaneous LP and reticular variant of oral LP being most commonly encountered. Dysplastic changes in oral LP demonstrated a value of 50% in our study, a value much higher when compared to previous reports, thus mandating vigilant identification of the same for appropriate patient management.

Keywords: Classical type, cutaneous lichen planus, dysplastic changes, oral lichen planus


How to cite this article:
Tickoo U, Bubna AK, Subramanyam S, Veeraraghavan M, Rangarajan S, Sankarasubramanian A. A clinicopathologic study of lichen planus at a tertiary health care centre in south India. Pigment Int 2016;3:96-101

How to cite this URL:
Tickoo U, Bubna AK, Subramanyam S, Veeraraghavan M, Rangarajan S, Sankarasubramanian A. A clinicopathologic study of lichen planus at a tertiary health care centre in south India. Pigment Int [serial online] 2016 [cited 2020 Apr 8];3:96-101. Available from: http://www.pigmentinternational.com/text.asp?2016/3/2/96/196301


  Introduction Top


Lichen planus (LP) is a clinically and histologically distinctive inflammatory disease whose aetiology still requires concrete elucidation. Suggested hypothesis for the same include genetic, infective and autoimmune mechanisms. Of late, there has been evidence portraying the role of auto-reactive cytotoxic T lymphocytes in the pathogenesis of LP.[1] Microscopically, LP is characterized by specific findings, making the diagnosis relatively simple. However, these histological findings may not be identifiable in all cases of LP. With respect to studies evaluating the clinicopathologic profile of LP, there certainly is a paucity of medical literature. We, therefore, attempted this study to scrutinize and analyse the clinicopathological findings of cutaneous and oral LP in a hospital-based population in Chennai.


  Methods Top


Our study was conducted in the Department of Dermatology of our Institute. This was a prospective, cross-sectional study done over a 1-year period. A total of 100 freshly diagnosed patients of LP were enrolled for the study, who were willing for a cutaneous/oral biopsy. Once the patients were selected, an informed and written consent was taken from each of them, following which relevant history concerning the disease was recorded. Baseline investigations including a liver function tests were performed, which was succeeded by a cutaneous biopsy or an oral biopsy based upon the clinical presentation of LP. Once the histopathology slide was ready, each slide was meticulously scrutinized and the findings carefully studied and evaluated. As all values in our study were qualitative, they were expressed as a percentage.


  Results Top


Out of the 100 patients studied, 60 were males and the remaining 40 females, with a male to female ratio being 3:2.

Majority of the patients belonged to the 31–40 years age group (40%), followed by 21–30 years (20%), 1–10 years (11%), 11–20 years (10%), 41–50 years (10%) and >50 years (9%).

Fifty-one patients had LP for a duration of less than 6 months prior to presentation in our out-patient department. In 28 patients, the duration ranged from 7 to 12 months. In 15 patients, the duration was greater than 24 months. In four patients, it ranged from 13 to 18 months and in the remaining two, the duration ranged from 19 to 24 months.

Pruritus was a predominant finding witnessed in 84 of our participants. Burning sensation in the oral cavity was seen in 20 participants and koebnerization was visualized in 38 of our participants.

Of the 100 patients in our study population, 42 of them had oral manifestations of LP and out of these, five patients were diagnosed with exclusive oral LP devoid of cutaneous features of LP. Sites commonly involved in the oral cavity included buccal mucosa in 33 (78.5%) patients, lips in 14 (33.3%) patients and tongue in 8 (19%) patients. Only two clinical types of oral LP were identifiable in our series, namely the reticulate type in 36 (85.7%) participants and erosive variant in the remaining 6 (14.3%).

Out of the 95 patients of cutaneous LP, the commonest type encountered was the classical type in 56 (58.9%) patients, followed by hypertrophic type in 27 (28.4%) patients, linear LP and lichen planopilaris (LPP) in 4 (4.2%) patients each and bullous LP and LP pigmentosus in 2 (2.1%) patients each.

Common sites involved in our participants included classical sites, namely the volar aspect of the wrist [Figure 1], sacral region and the region around the malleoli, face, both extremities, trunk, scalp, palms and soles, nails and genitals. The values for the same have been depicted in [Table 1].
Figure 1: Classical plaque of lichen planus on the volar aspect of the wrist

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Table 1: Anatomical sites involved in our patients with cutaneous LP

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Ungual involvement was a feature demonstrable in 17 patients of the 100 participants in our study. None of the patients had exclusive nail involvement. Longitudinal ridging (10, 58.8%) was the commonest nail finding visualized, followed by pitting (5, 29.4%), trachyonychia (2, 11.7%) [Figure 2], pterygium unguium (2, 11.7%), subungual hyperkeratosis (2, 11.7%), nail thinning (2, 11.7%) and longitudinal melanonychia (1, 5.8%).
Figure 2: Twenty-nail dystrophy

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The following diseases were found in association with LP in our study: diabetes mellitus (DM) in 10 patients, hypertension (HTN) and chronic hepatitis in seven patients, vitiligo in five patients and alopecia areata (AA) in two patients.

Of the 95 patients with cutaneous LP, the following findings were demonstrated on microscopic examination and have been summarized in [Table 2]. A cutaneous histopathology slide from a patient demonstrating classical findings of LP can be observed in [Figure 3].
Table 2: Histological findings in our patients of cutaneous LP

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Figure 3: Classical histologic features of cutaneous lichen planus demonstrating hyperkeratosis, hypergranulosis, saw toothing of the rete ridges and a dense band of inflammatory cells obscuring the dermo-epidermal junction (H&E ×200)

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Of the 42 patients with oral LP, the following results were obtained after carefully studying the slides under microscopy and have been summarized in [Table 3]. A histopathology specimen from the buccal mucosa demonstrating classical findings of oral LP can be observed in [Figure 4] and another specimen with dysplastic changes following oral LP can be seen in [Figure 5].
Table 3: Histological findings in our patients of oral LP

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Figure 4: Classical histologic features in oral lichen planus showing parakeratosis and a dense lymphocytic infiltrate obscuring the epidermal and dermal junction (H&E ×200)

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Figure 5: Dysplastic changes seen in oral lichen planus, demonstrating increased mitosis (H&E ×400)

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  Discussion Top


The present study was done with an attempt to throw light on the clinical and histopathological features in patients diagnosed with LP.

In our study, it was observed that the commonest age group affected was 31–40 years (40%), followed by 21–30 years (20%). This was in accordance with the study conducted by Singh and Kanwar,[1] a study done at Chandigarh, that depicted the 20–40 years age group to be maximally affected (53.7%). Similarly, in studies done by Kachhawa et al.[2] and Ireddy and Udbalkar,[3] 45.7 and 46.9% of the patients whose age ranged from 20 to 39 years were affected respectively. In another study conducted by Samman,[4] 60% of the patients in their series belonged to the 21–50 years age group. This was almost consistent with our findings, wherein 70% of the patients constituted this group. Surprisingly, in our study, we noticed an increased proportion of the disease affecting the paediatric population. Our series depicted 18% of the patients belonging to this category. This was in consonance with the findings of Singh and Kanwar,[1] wherein 17.2% of the cases of LP were diagnosed in the paediatric age group. The incidence of childhood LP has shown to be considerably higher in the Indian subcontinent when compared to studies from the west and has been described in various studies from India by Kanwar et al.,[5] Sharma and Maheshwari,[6] Handa and Sahoo[7] and Nanda et al.[8] Whether there exists an unidentified environmental factor responsible for the same requires further elucidation. According to past literature, LP affecting the elderly is rare. Our study demonstrated 7% of our participants above the age of 60 years. This was slightly less when compared to the data obtained from Samman,[4] wherein 12% of the patients belonged to the 60–70 years age group.

Studies in the past have demonstrated a variable male to female ratio. Our study depicted a male preponderance with a male to female ratio of 3:2. This finding of ours was in accordance to the values displayed by Singh and Kanwar[1] who also had a male to female ratio of 3:2. Similarly, Samman[4] also demonstrated a higher male preponderance in his study. In two other Indian studies, involving the paediatric age group by Kanwar and De[9] and Handa and Sahoo,[7] a male preponderance of 61 and 52.9% respectively was also identifiable. However, in another two Indian studies, one from Delhi[10] and another from Hyderabad,[3] an increased incidence of the disease amongst females with a male to female ratio of 0.8:1 and 1:1.42 respectively was noted. Bhattacharya et al.,[11] though, in their study demonstrated an equal occurrence of the disease in both males and females. Though there have been differences in most studies with respect to gender involvement for LP, it has been reported that there is a statistically significant increased frequency of Asian males in getting LP in both adults and children than their Caucasian counterparts.[12]

Pruritus as a noteworthy complaint was witnessed in 84% of our participants which was in accordance with the findings of Bhattacharya et al.,[11] who have reported a 79.3% incidence of itching in their series of patients affected with LP. In another study described by Ireddy and Udbalkar,[3] the proportion of patients presenting with pruritus was 82.6%, a finding closely simulating ours. Further, the findings of Kachhawa et al.[2] and Abdallat and Maaita[13] with respect to pruritus in their study also displayed agreement with our values, thereby making pruritus a hallmark feature associated with LP.

DM as an associated finding was observed in 10% of our patients. This was in consonance with the findings of Vijaysingham et al.,[14] who demonstrated an 11% incidence of DM and Antonide and Rebora[15] who identified DM to be present in 8.8% of their patients.

The occurrence of HTN in our study was 7%, a value much lower than the 21% depicted by Eisen.[16]

Vitiligo in our study amounted to 5% in our participants. This value was slightly higher than the findings by Anstey and Marks,[17] who reported an incidence of 1% in their series.

Recently, increasing evidence of the association of LP with liver disease has been demonstrated. Our series had a 7% incidence of chronic liver disease, a value that was intermediate to that of Rebora and Rongioletti[18] in whose report a value of 11.3% was witnessed and Bhattacharya et al.,[11] who demonstrated an incidence of 2.2%.

In our study, 37% of our participants had cutaneous LP along with oral LP. This was highly in accordance with the study conducted by Andreasen.[19] Oral LP as a sole manifestation was demonstrable in 5% of our participants. This was in consonance with the findings of Sehgal and Rege.[20] The lower incidence of oral LP could be attributed to the fact that majority of patients with oral lesions chiefly present to dental clinics. Out of the 42 patients having oral lesions of LP in our series, 85.7% had the reticulate morphology and the remaining 14.3% had erosive disease. Similar to our findings was the presentation of oral LP witnessed in a large case series of 611 patients by Thorn et al.,[21] who also demonstrated the increased occurrence of the reticulate variety of oral LP, followed by the erosive variant. The increased incidence of the reticulate variant of oral LP has again been reiterated by Eisen.[16] In our study, buccal mucosa (78.5%) was the commonest site to be involved in the oral cavity, followed by the lips (33%) and tongue (19%). In the study conducted by Andreasen[19] also, buccal mucosa was the most common site involved. However, their values demonstrating involvement of the buccal mucosa was a whooping 100%, a value extremely high when compared to ours.

Cutaneous lesions alone were demonstrable in 58% of our patients. This was lower when compared to the findings of Singh and Kanwar,[1] who showed a 70% occurrence of cutaneous LP alone in their patients.

Genital involvement was seen in 9% of our patients, slightly greater than the findings of Vijaysingham et al.[14] and Bhattacharya et al.,[11] wherein genital involvement of 6 and 5.2% respectively were demonstrated.

Lower limbs (78.9%) were the commonest site to be involved by LP in our participants [Figure 6] followed by the upper extremities (63.2%). This was in consonance with the findings of Ireddy and Udbalkar,[3] who also demonstrated lower extremities (66.3%) to be involved the most followed by the upper extremities (60.9%). Similarly, Kachhawa et al.,[2] Abdallat and Maaita[13] and Garg et al.[22] have also demonstrated lower limbs to be the most common site of involvement of LP. The incidence depicted by them was 61.9, 45.5 and 38% respectively, much lower when compared to our findings.Nail involvement was witnessed in 17% of our patients. Our values were slightly greater when compared to the findings of Zaias,[23] who demonstrated nail involvement in 10% of their series. Similarly, Samman[4] depicted ungual involvement in 15% of his patients.
Figure 6: Pigmented plaques of lichen planus over the lower extremities

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The commonest cutaneous LP encountered was the classical type (58.9%), followed by hypertrophic LP (28.4%). Vijaysingham et al.[14] and Bhattacharya et al.[11] have also depicted classical type of LP to be the most common type of LP encountered in their patients.

Familial cases of LP are thought to occur infrequently. In our study, it was demonstrable in only 1% of the participants. Similarly, family history was found in only 4 of 307 cases by Altman and Perry[24] and in 3 of 200 cases by Samman.[4]

Most of the characteristic histological features of LP were identifiable in our patients with LP, except in patients with LPP, wherein the characteristic presence of lymphocytic infiltrates around the pilosebaceous follicles was missing in all four patients. In our series, hyperkeratosis, hypergranulosis, liquefactive degeneration of the basal layer and subepidermal band like infiltrate of lymphocytes were seen in 93, 100, 94 and 93.3% respectively. This was almost at par with the findings of Ellis[25] who demonstrated values of 87, 93, 100 and 100% respectively to the above-mentioned parameters. Similar biopsy findings were observed from a study from Delhi,[10] wherein orthokeratosis and hypergranulosis were seen in 100% of their series, liquefactive basal cell degeneration in 100% and a band like lymphocytic subdermal infiltrate in 94% of their patients.


  Conclusion Top


To conclude, in our study, we observed that most patients with cutaneous LP presented with milder forms of the dermatoses. Most of the clinico-demographic data of our study was at par with previous literature. However, in our cases of oral LP, 50% demonstrated dysplastic changes, though they were clinically asymptomatic and surprisingly it was the reticulate variant that showed these pre-cancerous changes rather than the erosive type. Therefore, in all cases of oral LP, a strict observation protocol needs institution, thereby allowing clinicians to pick up early malignant changes and the need for oral mucosal biopsies for the same.

Acknowledgement

Dr. Leena Dennis Joseph, Professor, Department of Pathology, Sri Ramachandra University, Porur, Chennai, India.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Singh OP, Kanwar AJ. Lichen planus in India: An appraisal of 441 cases. Int J Dermatol 1976;15:752-6.  Back to cited text no. 1
    
2.
Kachhawa D, Kachhawa V, Kalla G, Gupta LP. A clinico-aetiological profile of 375 cases of lichen planus. Indian J Dermatol Venereol Leprol 1995;61:276-9.  Back to cited text no. 2
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3.
Ireddy SG, Udbalkar SG. Epidemiological study of lichen planus. BMR Med 2014;1:1-9.  Back to cited text no. 3
    
4.
Samman PD. Lichen planus. An analysis of 200 cases. Trans St Johns Hosp Dermatol Soc 1961;46:36-8.  Back to cited text no. 4
    
5.
Kanwar AJ, Handa S, Ghosh S, Kaur S. Lichen planus in childhood: A report of 17 patients. Pediatr Dermatol 1991;8:288-91.  Back to cited text no. 5
    
6.
Sharma R, Maheshwari V. Childhood lichen planus: A report of fifty cases. Pediatr Dermatol 1999;16:345-8.  Back to cited text no. 6
    
7.
Handa S, Sahoo B. Childhood lichen planus: A study of 87 cases. Int J Dermatol 2002;41:423-7.  Back to cited text no. 7
    
8.
Nanda A, Al-Ajmi HS, Al-Sabah H, Al-Hasawi F, Alsaleh QA. Childhood lichen planus: A report of 23 cases. Pediatr Dermatol 2001;18:1-4.  Back to cited text no. 8
    
9.
Kanwar AJ, De D. Lichen planus in childhood: Report of 100 cases. Clin Exp Dermatol 2010;35:257-62.  Back to cited text no. 9
    
10.
Parihar A, Sharma S, Bhattacharya SN, Singh UR. A clinicopathologic study of cutaneous lichen planus. J Dermatol Dermatol Surg 2015;19:21-6.  Back to cited text no. 10
    
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Bhattacharya M, Kaur I, Kumar B. Lichen planus: A clinical and epidemiological study. J Dermatol 2000;27:576-82.  Back to cited text no. 11
    
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Alam F, Hamburger J. Oral mucosal lichen planus in children. Int J Paediatr Dent 2001;11:209-14.  Back to cited text no. 12
    
13.
Abdallat SA, Maaita TJ. Epidemiological and clinical features of lichen planus in Jordanian patients. Pak J Med Sci 2007;23:92-4.  Back to cited text no. 13
    
14.
Vijaysingham SM, Lim KB, Yeoh KH, Cheong WL, Chong YY, Daniel M et al. Lichen planus: A study of 72 cases in Singapore. Ann Acad Med Singap 1988;17:541-4.  Back to cited text no. 14
    
15.
Antonide A, Rebora A. What lichen planus patients die of. A retrospective study. Int J Dermatol 1989;28:524-6.  Back to cited text no. 15
    
16.
Eisen D. The clinical features, malignant potential, and systemic association of oral lichen planus: A study of 723 patients. J Am Acad Dermatol 2002;46:207-14.  Back to cited text no. 16
    
17.
Anstey A, Marks R. Colocalization of lichen planus and vitiligo. Br J Dermatol 1993;128:103-4.  Back to cited text no. 17
    
18.
Rebora A, Rongioletti F. Lichen planus and chronic active hepatitis. A retrospective survey. Acta Derm Venereol 1984;64:52-6.  Back to cited text no. 18
    
19.
Andreasen JO. Oral lichen planus. 1. A clinical evaluation of 115 cases. Oral Surg Oral Med Oral Pathol 1968;25:31-42.  Back to cited text no. 19
    
20.
Sehgal VN, Rege VL. Lichen planus: An appraisal of 147 cases. Indian J Dermatol Venereol 1974;40:104-7.  Back to cited text no. 20
    
21.
Thorn JJ, Holmstrup P, Rindum J, Pindborg JJ. Course of various clinical forms of oral lichen planus. A prospective follow-up study of 611 patients. J Oral Pathol 1988;17:213-8.  Back to cited text no. 21
    
22.
Garg VK, Nangia A, Logani KB, Sharma RC. Lichen planus-a clinico-histopathological. Indian J Dermatol Venereol Leprol 2000;66:193-5.  Back to cited text no. 22
[PUBMED]    
23.
Zaias N. The nail in lichen planus. Arch Dermatol 1970;101:264-71.  Back to cited text no. 23
    
24.
Altman J, Perry HO. The variations and course of lichen planus. Arch Dermatol 1961;84:179-91.  Back to cited text no. 24
    
25.
Ellis FA. Histopathology of lichen planus based analysis of 100 cases. J Investig Dermatol 1967;48:143.  Back to cited text no. 25
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]


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