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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 27  |  Issue : 4  |  Page : 572-575

Hydroxychloroquin: A new hope in the management of oral lichen planus


1 Department of Oral Medicine and Radiology, Panineeya Mahavidyalaya Institute of Dental Sciences Research Centre, Hyderabad, India
2 Department of Oral and Maxillofacial Pathology, Panineeya Mahavidyalaya Institute of Dental Sciences and Research Centre, Hyderabad, India

Date of Submission14-Nov-2015
Date of Acceptance20-Jun-2016
Date of Web Publication19-Aug-2016

Correspondence Address:
Dr. Raj Kumar Badam
Department of Oral Medicine and Radiology, Panineeya Mahavidhyalaya Institute of Dental Sciences and Research Centre, Hyderabad - 500 060, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-1363.188765

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   Abstract 

Lichen planus (LP) is a chronic mucocutaneous, immune-mediated inflammatory disorder affecting middle-aged adults. It is a T-cell mediated disease in which the cytotoxic CD8+ T cells trigger apoptosis of the basal cells of the oral epithelium. It has different variants wherein the severe form includes bullous and ulcerative types. LP can significantly affect the quality of life with burning sensation and pain. Although a wide spectrum of treatment modalities are available for treating LP, the right choice of medicaments and/or combinations largely influence the final outcome of the treatment. We present a case of severe form of atrophic and ulcerative LP in a 17-year-old female in which we used a combination therapy for treatment, which resulted in a good prognosis on follow up.

Keywords: Hydroxychloroquine, mucocutaneous lesion, oral lichen planus


How to cite this article:
Pallerla SR, Badam RK, Boringi M, Pacha VB. Hydroxychloroquin: A new hope in the management of oral lichen planus. J Indian Acad Oral Med Radiol 2015;27:572-5

How to cite this URL:
Pallerla SR, Badam RK, Boringi M, Pacha VB. Hydroxychloroquin: A new hope in the management of oral lichen planus. J Indian Acad Oral Med Radiol [serial online] 2015 [cited 2021 Jul 26];27:572-5. Available from: https://www.jiaomr.in/text.asp?2015/27/4/572/188765


   Introduction Top


Lichen planus (LP) is a chronic inflammatory and immune-mediated mucocutaneous disease. It is commonly seen in the fourth decade of life, and women are affected more than men in a ratio of 1.4:1. The disease affects 1-2% of the population. Oral LP (OLP) is a T-cell mediated autoimmune disease in which the autocytotoxic CD8+ T cells trigger the apoptosis of the basal cells of the oral epithelium. [1] The treatment of LP depends on the severity and type of the disease and may range from simple topical applications of anti-inflammatory agents such as steroids to immune modulators for severe intractable forms. Hydroxychloroquine is an antimalarial drug having anti-inflammatory and immunomodulatory properties, which are helpful in treating LP by reducing the cytokine production, so that inflammation is reduced. Hydroxychloroquine has inhibitory action on Toll-like receptor 9, which is required for maturation of dendritic cells, thereby reducing the inflammation. Etiology behind LP is multifactorial comprising events that may take place at different time points. Therefore, by observing recalcitrant lesion on the tongue, we started antihistamines primarily followed by hydroxycholooquines to control the disease.


   Case History Top


A 17-year-old female patient reported to the department with the chief complaint of burning sensation and ulceration in her mouth since 3 months. On eliciting the chief complaint, the patient gave a history of burning sensation on consuming hot and spicy food since 3 months which was initially mild and gradually increased up to the present stage. Patient also gave a history of inability to move the tongue due to ulcerations. On intraoral examination, there were multiple erythematous (erosive) lesions, interspersed with thin white keratotic striae arranged in a reticular fashion (Wickham striae) [Figure 1]. Multiple small ulcers measuring approximately 2-3 mm were also seen on the right and left buccal mucosae which were extending from vestibular sulcus of the first premolar to vestibular sulcus of the second molar on both the right and left sides. A solitary ulcer with irregular borders on the anterior two-third of dorsum of the tongue with yellowish exudates covering the surface was also seen [Figure 2].
Figure 1: Intraoral image of right buccal mucosa showing erosive lesion interspersed with Wickham's striae

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Figure 2: Intraoral image of tongue showing ulcerative lesion with irregular borders

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On correlating clinical findings and history, a provisional diagnosis of erosive LP of the right and left buccal mucosae and tongue was suggested. Differential diagnosis of lichenoid reaction, lupus erythematosus, pemphigus, mucus membrane pemphigoid, erythematous candidiasis, and chronic ulcerative stomatitis were also considered. After preliminary investigations, incisional biopsy was done at the right buccal mucosa and left side of the anterior two-third of the tongue. The biopsy revealed multiple chronic inflammatory cells with lymphocytic infiltration suggestive of erosive LP of the right buccal mucosa and chronic ulcerative lesion of the tongue [Figure 3] and [Figure 4].
Figure 3: Histopathological image (10×) showing saw tooth retepegs

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Figure 4: Histopathological image (40×) showing lymphocytic infiltration

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On considering the acute phase of the disease, the patient was advised topical triamcinolone acetonide 0.1% thrice a day, clotrimazole topical antifungal (Candid mouth paint) thrice daily, antioxidants, and antihistamines (Atarax 25 mg TID) for 2 months. On the first follow-up, moderate remission of lesions on both sides of mucosa was seen [Figure 5], however, the lesion on the tongue remained. After preliminary investigations, hydroxychloroquine (HCQ) 200 mg once daily was started for the patient because the tongue lesions did not respond. The topical steroids and antioxidants were continued without change in dosage. On the next follow-up, after a week, the tongue lesions showed good remission along with alleviation of symptoms. HCQ was continued for 3 months along with antioxidants and topical steroids till the patient showed remission of lesions [Figure 6]. Periodically, the patient was advised to undergo complete hematological examination to check for bone marrow suppression. Iron supplements were added in the last 1 month to the treatment regimen because the Hb% decreased to 11 g/dl which could be due to inability of the patient to take proper nutrition. There was no recurrence of the lesions for the next 8 months and the patient is still on follow-up till date.
Figure 5: Post-treatment image of buccal mucosa

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Figure 6: Post-treatment image of tongue

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   Discussion Top


The prevalence of OLP is reported between 0.1 and 2.2%. [2] Among the patients, the proportion of women is higher than that of men in a ratio of 3:2. [3] It affects between the third and sixth decade, however, it can occur at any age. In the present case, the patient was in the second decade. Approximately 50% of females with OLP were reported to have undiagnosed vulvar LP, but no such findings was seen in our case. [4] The most common sites are buccal mucosa (84%) and to a lesser extent on the tongue, lips, gingiva floor of the mouth, and palate. [5] These types often coexist in the same individual, which was a finding in the present case also, presenting with lesions on the buccal mucosa and tongue. The most common clinical presentation is whitish keratotic striae in a reticulated pattern, [6] which was seen in our case also. The lesion on the tongue is seen on the anterior two-third of the tongue with ulcerations and restricted tongue movements, as seen in our case. OLP may cause symptoms ranging from mild discomfort to severe burning sensation, restricting intake of food. More severe symptoms are commonly associated with the atrophic and ulcerative subtypes.

The choice of treatment depends on the severity of the disease and patient compliance. Anti-inflammatory drugs commonly used are steroids, which can be given as topical systemic therapy. Commonly used drugs are triamcenalone acetonide, dexamethasome, and prednisalone. [3],[7] In the present case, considering the acute symptoms, we started with topical triamcenalone acetonide (Tess Ointment 0.1%) and cotrimazole ointment (Candid mouth paint) along with antioxidants and antihistamines.

HCQ, a hydroxylated form of antimalarial drug chloroquin, is known for its anti-inflammatory, immunomodulating, antihyperlipidemic, and antithrombotic effects. HCQ decreases inflammatory cytokine production and antigen processing necessary for antigen presentation of autoantigens. [8] However, long-term usage causes retinal damage and visual changes. It is contraindicated in patients with liver cirrhosis. Because LP is a T-cell mediated autoimmune disease, HCQ with its anti-inflammatory effects has been used earlier as a promising drug for its treatment. In the present case, HCQ (200 mg/day) in a single dose was given for the recalcitrant tongue lesion, which did not respond to the empirical therapy. The patient showed remission of the lesions, and there was no recurrence during the next 8 months of follow-up post administration of HCQ.


   Conclusion Top


The current case focuses on reporting an uncommon combination of erosive and atrophic type of LP which was recalcitrant to empirical therapy. Although topical steroids were of little help in reducing the lesions, HCQ proved to be very useful in total remission of the lesions and symptomatic relief to our patient. A proper treatment plan, based on the type and severity of the disease, can prove to be beneficial, thereby improving patient care for those suffering with OLP as well as improving the quality of life. HCQ can be a promising drug in treating OLP and holds great potential for more research and trials related to this treatment modality.

Acknowledgement

Dr. J. Vijay Kumar, Professor, Department of Oral and Maxillofacial Pathology, Panineeya Mahavidhyalaya Institute of Dental Sciences and Reasearch Centre, Hyderabad.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Gorouhi F, Davari P, Fazel N. Cutaneous and mucosal lichen planus: A comprehensive review of clinical subtypes, risk factors, diagnosis, and prognosis. Scientific World J 2014;2014:742826.  Back to cited text no. 1
    
2.
Murti PR, Daftary DK, Bhonsle RB, Gupta PC, Mehta FS, Pindborg JJ. Malignant potential of oral lichen planus: Observations in 722 patients from India. J Oral Pathol 1986;15:71-7.  Back to cited text no. 2
[PUBMED]    
3.
Ingafou M, Leao JC, Porter SR, Scully C. Oral lichen planus: A retrospective study of 690 British patients. Oral Dis 2006;12:463-8.  Back to cited text no. 3
    
4.
Pakfetrat A, Javadzadeh-Bolouri A, Basir-Shabestari S, Falaki F. Oral lichen planus: A retrospective study of 420 Iranian patients. Med Oral Patol Oral Cir Bucal 2009;14:E315-8.  Back to cited text no. 4
    
5.
Eisen D. The clinical features, malignant potential, and systemic associations of oral lichen planus: A study of 723 patients. J Am Acad Dermatol 2002;46:207-14.  Back to cited text no. 5
    
6.
Sousa FA, Rosa LE. Oral lichen planus: Clinical and histopathological considerations. Braz J Otorhinolaryngol 2008;74:284-92.  Back to cited text no. 6
    
7.
Lavanya N, Jayanthi P, Rao UK, Ranganathan K. Oral lichen planus: An update on pathogenesis and treatment. J Oral Maxillofac Pathol 2011;15:127-32.  Back to cited text no. 7
[PUBMED]  Medknow Journal  
8.
Willis R, Seif AM, McGwic Jr G, Martinez M, Gonzalez EB, Dang N, et al. Effect of hydroxycholorquine treatment on proinflamatory cytokines and disease activity in SLE patients: Data from LUMINA (LXXV), a multiethenic US cohort. Lupus 2012;21:830-5.  Back to cited text no. 8
    


    Figures

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



 

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