The answer is B . Erosive lichen planus .
I N T R O D U C T I O N
Lichen planus ( LP ) is a common chronic inflammatory mucocutaneous disorder that usually affects middle-aged adults , with a slight female predominance . The skin is the most common site , 1 and the etiology of LP is still unknown . The skin lesions usually present as pruritic , purple , polygonal papules involving the flexural areas . Upon close examination , white lacey lines ( Wickham striae ) can typically be seen on the papules .
The oral lesions present in different forms : reticular , plaque-like , atrophic , and erosive . 2 , 3 However , reticular and erosive forms of the disease predominate . The reticular form is the most common , presenting classically with an asymptomatic white lacey pattern ( Wickham striae ) usually seen on the buccal mucosa bilaterally , although other oral cavity sites can also be affected . 4 The erosive form is noted more frequently by clinicians , because it is associated with symptoms such as pain or burning , which bring affected patients to seek medical assistance . Clinically , the erosive form may present as an erythematous ulcerative area often surrounded by a network of white striations . Any mucosal surface within the oral cavity can be affected ; gingival involvement can present clinically as desquamative gingivitis . Desquamative gingivitis can also be the intraoral manifestation of other ulcerative conditions , such as benign mucous membrane pemphigoid and pemphigus vulgaris , which should be ruled out . The reticular form of LP may not warrant a biopsy , due to its classical clinical presentation and asymptomatic nature ; all other forms should be biopsied to rule-out other possible conditions .
Sometimes lesions that look like LP are given a histopathologic diagnosis of “ lichenoid mucositis ”, because they differ from LP under the microscope . These often arise as a contact reaction to materials ( e . g . cinnamon flavoring , toothpaste , mouthwash , amalgam ), Management of erosive LP can be challenging due to the chronic and recalcitrant nature of the disorder . LP cannot be cured , so management should be aimed at alleviating the patient ’ s symptoms and achieving symptom-free periods of remission . The mainstay of treatment for erosive lichen planus is the use of steroids , topical or systemic , depending on the extent and severity of the lesions . Examples of topical steroids commonly used for LP include hydrocortisone gel 1.0 %, triamcinolone acetonide ( Kenalog ® in Orabase ®) 0.1 %, betamethasone valerate ( Valisone ®) 0.1 %, fluocinonide ( Lidex ®) gel 0.05 %, dexamethasone oral rinse ( Decadron ®) 0.5mg / 5ml , clobetasol propionate ( Temovate ® ointment ) 0.05 %). Prednisone tablets are usually the form of systemic steroid used . The use of steroids by patients requires proper monitoring by the clinician due to its associated side-effects and the effects of sudden withdrawal of systemic steroid medication . This modality may be beyond the scope of a general dentist , hence the need to refer to a specialist . Common side-effects with topical steroids in the oral cavity are fungal infection ( candidiasis ) and mucosal atrophy .
Side-effects with long-term systemic steroids include increased appetite and weight gain , osteoporosis , elevated blood sugar , elevated blood pressure , behavioral and mood changes , increased risks of developing gastrointestinal ulcers , and cataracts . New therapies have been introduced or are under investigation , such as the use of immunomodulators ( e . g ., thalidomide , imiquimod , pimecrolimus , and sirolimus ), biologics ( e . g ., rituximab , alefacept , and adalimumab ), and herbal medicines ( e . g ., aloe vera , curcuminoid , and purslane ). 6 All of these therapies have their shortcomings and side-effects . Our patient was managed with the use of dexamethasone oral rinse and prednisone tablets .
D I S C U S S I O N
Choice A . Erythema multiforme minor ( EM ) is a condition usually seen in young adults , associated with erythematous erosive lesions of the skin and oral cavity . Fever and malaise may precede the onset of the lesions . While the cutaneous lesions often vary , target or “ bull ’ s eye ” lesions are characteristic of this condition . 7 These target lesions are typically erythematous , slightly raised , with concentric rings and central erosion . They are usually found on the extremities , with the palmar surface being the most common location . The oral cavity may be involved with erythematous or ulcerated lesions and can affect any site within the oral cavity . Wickham striae are not seen in lesions of EM . Hemorrhagic crusting of the lips is a common and characteristic finding associated with this condition . The etiology of EM likely varies and is not fully understood , but includes exposure to certain drugs . In addition , many cases of EM appear to be associated with an infectious agent , most such cases being linked to herpes simplex viral infection or mycoplasma pneumonia . 8 , 9 Distinguishing this condition from LP is important , due to its management . If EM is misdiagnosed and managed as LP , the condition may get worse . The use of steroids in treating cases of HSV-associated EM might lower the patient ’ s resistance to fight infections , thereby causing recurrent EM . 10 The clinical history of fever , malaise and presence of hemorrhagic crusting of the lips and target lesions on the skin should help differentiate EM from LP .
Choice C . Chronic cutaneous lupus erythematosus ( CCLE ) also called discoid lupus erythematosus is an autoimmune condition predominantly affecting mucocutaneous areas . It manifests on the skin as erythematous scaly round patches which may heal with atrophic scarring , leaving a central pale zone . The lesions are commonly found in the facial region , usually involving the skin over the malar bone . The lesions of the oral cavity clinically resemble erosive lichen planus . 11 The etiology of CCLE is unknown , but exposure to sunlight may trigger or exacerbate the condition . 10 The oral component of this condition can be treated with steroids . Antimalarial medications have been found useful in cases unresponsive to steroids . CCLE can
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