Elsevier

Clinics in Dermatology

Volume 28, Issue 5, September–October 2010, Pages 563-567
Clinics in Dermatology

Premalignant nature of oral and vulval lichen planus: Facts and controversies

https://doi.org/10.1016/j.clindermatol.2010.04.001Get rights and content

Abstract

Although many classifications include oral lesions of lichen planus in the category of a premalignant condition, there is still much discussion about whether the mucous membranes lesions should be characterized as an intrinsically premalignant condition or merely as a facilitator of the action of a carcinogenic factor. The possibility that an epidermoid carcinoma can emerge at the site of lichen planus lesions, mainly in mucous membranes, has been shown; however, several published cases omit information about other potential risk factors. This prevents a complete analysis of the triggering relationship between lichen planus and squamous cell carcinoma. This contribution reviews the literature on this subject. The question of whether oral or vulval lichen planus, or both, are premalignant conditions will only be answered after prospective studies with large samples and extensive follow-up are performed, taking into consideration the great variety of risk factors involved, together with the establishment of a consensus in relation to the points still without agreement.

Introduction

Lichen planus (LP) is an inflammatory dermatosis of still unknown etiology. LP is currently considered to be a probable autoimmune process, triggered by antigenic alterations on the cell surface of the basal layer of the epithelium.1, 2 The cutaneous lesions present clinically as polygonal, shiny, isolated, and symmetrical papules of erythematous-violet coloration with whitish streaks on the surface (Wickham striae). Although LP can affect any part of the tegument, it presents a preference for the flexural surfaces of the forearms, thighs, third distal of legs, abdomen, and sacral area. It can also involve fingernails and mucous membranes.3, 4

Mucous membrane lesions in LP were first described in 1869 by Erasmus Wilson,5 who presented 50 patients with LP, including 3 with lesions in the mouth. The most frequently affected mucous membrane is the mouth, although lesions have been described in the mucosa of the genitalia, nose, pharynx, larynx, esophagus, stomach, intestines, anus, conjunctiva, urethra, and bladder.6

Several publications have correlated mucous membrane lesions with the development of epidermoid carcinoma, mainly the oral lesions,7 and with lesser frequency, the vulval lesions.7, 8 Some rare cases of malignant transformation of cutaneous lesions have also been described, without indicating an increased risk in the healthy population.9 Those occurrences are more related to a predisposing factor than to an intrinsic potential of malignant evolution. Prolonged use of arsenic, previous irradiation of the lesion site and presence of hypertrophic or chronic verrucous lesions of lower limbs were possibly involved in the eventual malignancy reported in those patients.10, 11, 12

The World Health Organization (WHO) defines a premalignant condition as “a generalized state associated with a significantly increased risk of cancer,” and includes the oral lesions of LP in that classification.13 Still a major topic of discussion, however, is whether LP of the mucous membranes should be characterized as an intrinsically premalignant condition or merely as a facilitator of the action of carcinogenic agents, such as tabagism (the condition created by excessive tobacco use), alcoholism, nutritional errors, poor hygiene, immunosuppressive states, family history, hepatitis C, and viruses with oncogenic potential, such as herpesvirus types I and II, Epstein-Barr, and the human papillomavirus.14, 15

Section snippets

Oral lichen planus

Oral lichen planus (OLP) can involve any area of the oral cavity but is found more frequently in the buccal mucosa.16 Its general prevalence ranges from 1% to 2% of the population and from 50% to 77% in patients with LP.4, 17 OLP usually affects individuals aged between 40 and 70 years and is rarely observed in children.18 The oral lesions can precede or accompany the cutaneous lesions and occur as isolated manifestation of the disease in 20% to 30% of patients.1, 2

OLP presents great clinical

Vulval LP

Genital LP lesions can be observed in both sexes, and the shortage of publications about this location of the disease indicates that it is probably less common than the cutaneous and oral lesions. The exact prevalence of vulval lichen planus (VLP) lesions is not known; however, a study published in 1998 showed VLP lesions in 51% of 37 patients LP patients.8 The sample in that study was small, but its result may be an indication that VLP is more prevalent than thought. Many cases are probably

Conclusions

Despite being quite rare, the possibility of the emergence of an epidermoid carcinoma exists at the site of the lesions of the disease, mainly in the lesions of the mucous membranes. The attempt to attribute to OLP or VLP the capacity to self-develop malignancy, independently of the action of possible associated risk factors, should still generate a lot of discussion. Although research groups linked to the WHO have been emphatic about placing OLP as a premalignant condition, a consensus does

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