Hepatitis C virus and lichen planus in Nigerians: any relationship?

BACKGROUND: The association of lichen planus with Hepatitis C virus (HCV) has been widely reported in the literature. No such association, however, has been reported amongst black Africans in whom HCV is thought to be endemic. Lichen planus is a frequently encountered dermatosis in this racial group as well. The aim of this study was to determine the prevalence of anti-HCV amongst Nigerians with lichen planus. METHODS: Fifty-seven Nigerians with lichen planus (LP group) and 24 patients with other dermatoses not reportedly associated with HCV (control group A) and 24 apparently normal subjects (control group B) were screened for the presence of anti-HCV by second generation ELISA. RESULTS: Nine (15.8%) of the 57 LP group, 6 (25%) of the 24 control group A and none out of the 24 control group B were seropositive for anti-HCV. CONCLUSION: The prevalence of anti-HCV amongst Nigerian with lichen planus is lower than amongst patients with other dermatoses not associated with HCV but higher than amongst apparently normal control. It would appear that the prevalence of HCV is high in Nigeria and not necessarily in lichen planus as a specific entity.     

Hepatitis C virus infection prevalence in lichen planus: examination of lesional and normal skin of hepatitis C virus-infected patients with lichen planus for the presence of hepatitis C virus RNA

Hepatitis C virus (HCV) is the main cause of parenterally transmitted non-A, non-B viral hepatitis. In recent years, a significant association between lichen planus and chronic HCV infection has been reported. Anti-HCV antibody status was evaluated by ELISA in 54 patients with lichen planus and 54 patients with minor dermatological disorders. PCR was used to examine HCV RNA from serum and lesional and nonlesional cutaneous biopsy samples of HCV-infected patients. Seven patients with lichen planus (12.9%) and two patients in the control group (3.7%) were anti-HCV antibody positive. Five out of seven patients with anti-HCV antibodies had demonstrable HCV RNA in lesional skin biopsies. The viral RNA was absent in three out of four patients with lichen planus whose serum samples were positive for HCV RNA and agreed to biopsy of nonlesional skin. The prevalence of HCV infection is not increased in Turkish patients with lichen planus. However our findings suggest that the virus may play a potential pathogenic role by replicating in cutaneous tissue and triggering lichen planus in genetically susceptible HCV-infected patients.     

Oral lichen planus: different clinical features in HCV-positive and HCV-negative patients

BACKGROUND: Hepatitis C virus (HCV) infection induces variable dermatologic manifestations. OBJECTIVE: To determine whether differences exist in the clinical features and behavior of oral lichen planus (OLP) between HCV-positive (HCV+ve) and HCV-negative (HCV-ve) patients. METHODS: Two hundred and sixty three patients (156 women and 107 men), with a mean age of 55.5 years, with OLP (76 HCV+ve and 187 HCV-ve) were clinically evaluated. Previously, all local factors that could modify the clinical characteristics were removed and were monitored carefully following morphology. RESULTS: In both groups, the prevalent clinical form of OLP was the mixed form (33.1% in HCV-ve and 35.5% in HCV+ve patients), in which reticular-plaque lesions coexist with atrophic-erosive ones. The reticular form was more frequent in HCV+ve (25%) than in HCV-ve (18. 7%) patients, whereas plaque lesions were more prevalent in HCV-ve (15.5%) than in HCV+ve (5.2%) patients (P < 0.01, chi-squared test). There were no significant differences in the frequency of erosive (27.2% in HCV-ve and 27.6% in HCV+ve) and atrophic (5.3% in HCV-ve and 5.2% in HCV+ve) forms between the two groups. CONCLUSIONS: Our findings show that there were statistically significant differences between OLP-HCV-ve and OLP-HCV+ve groups for reticular and plaque clinical forms. These findings underline the importance of liver examination in all OLP patients, including cases with mild, asymptomatic keratotic forms of the disease.     

Increased frequency of HLA-DR6 allele in Italian patients with hepatitis C virus-associated oral lichen planus

BACKGROUND: Recent controlled studies have confirmed that hepatitis C virus (HCV) is the main correlate of liver disease in patients with lichen planus (LP), mainly in southern Europe and Japan. However, a low prevalence of HCV infection has been found in LP patients in England and northern France, and significant differences in serum HCV RNA levels or HCV genotypes have not been found between LP patients and controls. Thus host rather than viral factors may be prevalent in the pathogenesis of HCV-related LP. The HLA-DR allele may influence both the outcome of HCV infection and the appearance of symptoms outside the liver. OBJECTIVES: To assess whether major histocompatibility complex class II alleles play a part in the development of HCV-related LP. METHODS: Intermediate-resolution DRB typing by hybridization with oligonucleotide probes was performed in 44 consecutive Italian oral LP (OLP) patients with HCV infection (anti-HCV and HCV RNA positive), in an age, sex and clinically comparable disease control group of 60 Italian OLP patients without HCV infection (anti-HCV and HCV RNA negative), and in 145 healthy unrelated Italian bone marrow donors without evidence of liver disease or history of LP and with negative tests for HCV. RESULTS: Patients with exclusive OLP and HCV infection possessed the HLA-DR6 allele more frequently than patients with exclusive OLP but without HCV infection (52% vs. 18%, respectively; Pc (Pcorrected) = 0.028, relative risk = 4.93). We did not find any relationship between mucocutaneous LP, HCV infection and HLA-DR alleles. CONCLUSIONS: HCV-related OLP therefore appears to be a distinctive subset particularly associated with the HLA class II allele HLA-DR6. This could partially explain the peculiar geographical heterogeneity of the association between HCV and LP.     

Griseofulvin therapy of lichen planus

Thirty-one patients who had lichen planus treated with griseofulvin were randomly selected for review from a group of patients with lichen planus seen at the Mayo Clinic between January 1976 and June 1980; two patients were excluded because of lack of adequate follow-up. Of the 11 patients with only oral lesions, 6 showed a marked improvement or complete remission. Of the 18 patients with lichen planus involving one or more sites with or without oral lesions, 15 had cutaneous lesions. Three of the 15 had improvement of their cutaneous lesions; however, 1 of the 3 continued to develop new lesions, although old ones were improving. In patients with recalcitrant, symptomatic oral lichen planus, a trial of griseofulvin would seem justified. Success in patients with cutaneous lichen planus is less likely; however, griseofulvin may afford relief in selected patients. This study indicates that further prospective studies are needed to clarify the efficacy of griseofulvin in lichen planus.     

Lichen planus and Hepatitis C: a case-control study

Background

The association of lichen planus with hepatitis C (HCV) has been widely reported in the literature. However, there are wide geographical variations in the reported prevalence of HCV infection in patients with lichen planus. This study was conducted to determine the frequency of hepatitis C in Iranian patients with lichen planus at Razi hospital, Tehran.

Methods

During the years 1997 and 1998, 146 cases of lichen planus, 78 (53.1%) women and 69 (46.9%) men were diagnosed. They were diagnosed on the basis of the usual clinical features and, if necessary, typical histological findings. The patients were screened for the presence of anti-HCV antibodies by third generation ELISA and liver function tests. We used the results from screening of blood donors for anti HCV (carried out by Iranian Blood Transfusion Organization) for comparison as the control group.

Results

Anti-HCV antibodies were detected in seven cases (4.8%). This was significantly higher than that of the blood donors' antibodies (p < 0.001). The odds ratio was 50.37(21.45–112.24). A statistically significant association was demonstrated between erosive lichen planus and HCV infection. Liver function tests were not significantly different between HCV infected and non-infected patients.

Conclusion

HCV apears to have an etiologic role for lichen planus in Iranian patients. On the other hand, liver function tests are not good screening means for HCV infection.     

Oral lichen planus and allergy to dental amalgam restorations

OBJECTIVES: To determine contact allergies in patients with oral lichen planus and to monitor the effect of partial or complete replacement of amalgam fillings following a positive patch test reaction to ammoniated mercury, metallic mercury, or amalgam. DESIGN: In group A (20 patients), the oral lesions were confined to areas in close contact with amalgam fillings. In group B (20 patients), the lesions extended 1 cm beyond the area of contact with amalgam fillings. In group C (20 patients), the oral lesions had no topographic relationship with amalgam fillings. Partial or complete replacement of amalgam fillings was recommended if there was a positive patch test reaction to ammoniated mercury, metallic mercury, or amalgam. Control group D (20 patients) had signs of allergic contact dermatitis. RESULTS: Amalgam fillings were replaced in 13 patients of group A, with significant improvement. Dental amalgam was replaced in 8 patients of group B, with significant improvement. In group C, amalgam replacement in 2 patients resulted in improvement in 1 patient. These results were evaluated after 3 months. No positive patch test reactions to mercury compounds were found in patients with concomitant cutaneous lichen planus and in group D. CONCLUSIONS: Contact allergy to mercury compounds is important in the pathogenesis of oral lichen planus, especially if there is close contact with amalgam fillings and if no concomitant cutaneous lichen planus is present. In cases of positive patch test reactions to mercury compounds, partial or complete replacement of amalgam fillings will lead to a significant improvement in nearly all patients.     

Verrucous carcinoma in association with hypertrophic lichen planus

Neoplastic transformation of lichen planus is a rare event. However, squamous cell carcinoma may develop in 0.3%–3% of patients with the oral form of the disease. On the other hand, less than 30 cases arising in cutaneous lichen planus have been reported, and only four cases of verrucous carcinoma in association with either form, one with an oral lesion and three with cutaneous lesions (one hypertrophic and one ulcerative).
This report describes the unusual progression of a hypertrophic lichen planus plaque of the right leg to a verrucous carcinoma in a 40-year-old woman.     

Lichen planus and hepatitis C virus: prevalence and clinical presentation of patients with lichen planus and hepatitis C virus infection

Summary Although cases of lichen planus (LP) associated with hepatitis C virus (HCV) infection have been described, the association between the two diseases has not been established because the geographic origin of patients could be an important factor in HCV prevalence in patients with LP. The serum samples of 78 consecutive patients with cutaneous and/or mucous LP and 82 control patients were analysed for the presence of antibodies to HCV by enzyme-immunoassay and for the presence of antigens of HCV by two-stage polymerase chain reaction (PCR). The clinical features of patients with LP associated with HCV infection were compared with patients with LP without HCV infection. Sixteen of the 78 (20%) patients had anti-HCV antibodies. In 13 of these 16 cases (81%), HCV-RNA was detected by PCR in serum samples. In the 82 control patients, anti-HCV antibodies was observed in two (2·4%) patients. We have found a statistically significant association (P < 0·05) between erosive LP and HCV infection. We conclude that the high prevalence of HCV-RNA in patients with LP provides some evidence for the role of HCV in the pathogenesis of LP. Our results suggest an association between erosive LP and HCV infection.     

Photopheresis: an alternative therapeutic approach in corticoresistant erosive oral lichen planus

BACKGROUND: The immunomodulatory effect of extracorporeal photochemotherapy (photopheresis) coupled with its efficacy in lymphocytic skin diseases provides a rationale for its use for erosive lichen planus. We report two cases of chronic oral erosive and corticoresistant lichen planus successfully treated with photopheresis. PATIENTS AND METHODS: Case 1. A 61-years-old man had erosive oral lichen planus for four years. Oral steroids were contra-indicated due to iatrogenic pancreatitis. After nine photopheresis sessions, subjective improvement occurred and the oral lesions were stabilized. Case 2. A 17-years-old woman presented corticodependent oral and genital erosive lichen planus and cutaneous lesions. After seven sessions of photopheresis, the patient was able to eat again and the pain decreased. After 20 sessions, the cutaneous lichen planus disappeared and complete remission of the mucous lesions was obtained without corticotherapy. DISCUSSION: These two cases, together with 23 other cases reported elsewhere, strongly suggested the value of photopheresis in the treatment of erosive lichen planus. However, relapses after treatment withdrawal appear extremely frequent.     

Lichen planus and malignancy. An epidemiologic study of 2071 patients and a review of the literature

The literature contains 36 reports of squamous cell cancer associated with lichen planus, and several reports on increased frequency of oral cancer in patients with oral lichen planus. To examine the risk of malignant transformation, 2071 patients with lichen planus were followed up for an average of 9.9 years. Only eight squamous cell carcinomas were observed in this population after the first visit for lichen planus, producing a morbidity ratio of 1.0 (95% confidence interval, 0.9 to 1.2). Significant increase for oral cancer was observed in male subjects, with a morbidity ratio of 5.9 (95% confidence interval, 2.5 to 11.4). This study indicates that patients with cutaneous lichen planus do not carry an increased risk of malignant transformation of the skin lesions or internally; however, there is increased risk of oral cancer.     

Mucosal vulval lichen planus: outcome, clinical and laboratory features

BACKGROUND: Mucosal lichen planus of the vulva is a rare but increasingly recognized condition. It has potentially severe complications such as fusion of the labia and vagina; the risk of developing squamous cell carcinoma (SCC) may be increased. An association between hepatitis B and C infection and skin or oral lichen planus appears to exist in certain geographical areas. OBJECTIVE: To investigate the course of mucosal vulval lichen planus, its response to treatment and associated laboratory features. SUBJECTS AND METHODS: Forty-four women with mucosal vulval lichen planus were studied between 1997 and 2000 and laboratory data were collected. RESULTS: Thirty of 44 patients had additional oral lesions, only nine had cutaneous findings compatible with lichen planus. We did not find an association with antibodies to hepatitis B or C virus in this British study population. All women were treated with potent to very potent topical corticosteroids; however, in the majority of patients symptoms persisted. In seven (16%) patients vulval lichen planus was in remission after a disease duration between 2 and 18 years (mean 10.6 years). One patient developed a vulval SCC. CONCLUSIONS: Screening for hepatitis B and C in women with mucosal vulval lichen planus in the UK seems unnecessary. We recommend long-term follow-up, and that all non-healing ulcerative and papular lesions should be biopsied.     

Hepatitis C virus and its cutaneous manifestations: treatment in the direct‐acting antiviral era

New all‐oral direct‐acting antivirals (DAA) have changed the hepatitis C virus (HCV) treatment landscape. Given that dermatologists frequently encounter HCV‐infected patients, knowledge of the current treatment options and their utility in treating HCV‐associated dermatologic disorders is important. In addition to highlighting the new treatment options, we review four classically HCV‐associated dermatologic disorders – mixed cryoglobulinaemia (MC), lichen planus (LP), porphyria cutanea tarda (PCT) and necrolytic acral erythema (NAE) – and examine the role for all‐oral direct‐acting antiviral (DAA) regimens in their treatment. A literature search of English‐language publications was conducted of the PubMed and EMBASE databases using search terms including ‘hepatitis C’, ‘direct acting antivirals’, ‘cutaneous’, ‘mixed cryoglobulinemia’, ‘necrolytic acral erythema’, ‘lichen planus’, ‘porphyria cutanea tarda’, ‘rash’, as well as specific drug names, related terms and abbreviations. Currently, limited data exist on the use of DAAs in HCV‐infected patients with cutaneous side‐effects, although treatment of the underlying HCV is now recommended for nearly all patients, with the new drugs offering much‐improved dosage schedules and side‐effect profiles. The most data exist for MC, in which several studies suggest that DAAs and achievement of sustained virologic response (SVR) improve cutaneous symptoms. Studies of both older and newer regimens are limited by their small size, retrospective nature, lack of appropriate controls and wide variability in study protocols. Given the strong association, screening for HCV should be considered in patients with MC, LP, PCT and NAE.     

Lichen planus and other cutaneous manifestations in chronic hepatitis C: pre- and post-interferon-based treatment prevalence vary in a cohort of patients from low hepatitis C virus endemic area

Background Several controversies exist regarding the relationship between hepatitis C virus (HCV) infection and some cutaneous manifestations, lichen planus (LP) in particular. Objectives To determine the prevalence of LP and other cutaneous manifestations in a cohort of patients infected with HCV from low HCV endemic area of Slovenia, to correlate findings with chosen biological variables and to assess the role of interferon (IFN)‐based treatment of HCV infection in cutaneous manifestations. Methods A total of 171 consecutive HCV‐seropositive patients and 171 HCV‐seronegative age‐ and gender‐matched controls were studied prospectively. Prevalence of cutaneous manifestations, comparison between study patients and controls and correlation of skin findings with demographic, biochemical, virological and liver histologic findings as well as IFN‐based therapy were assessed. Results Overall presence of LP in HCV‐seropositives was 2.3%; although LP was not found in controls, the difference was not statistically significant (P = 0.123). Significantly higher than in controls was the prevalence of pruritus (31.0%, P < 0.001), dry skin (16.4%, P < 0.001) and hair loss (9.9%, P < 0.001). In IFN‐based treatment naïves, skin findings were more frequent compared with controls, but not significantly, with no correlation to chosen biological variables. Current IFN‐based treatment was significantly connected to pruritus (P < 0.001) and dry skin (P < 0.001). Compared with treatment naïves, in post‐treated patients pruritus (odds ratio, 19.13; 95% confidence interval, 6.85–53.42; P < 0.001), dry skin (odds ratio, 4.21; 95% confidence interval, 1.44–12.31; P < 0.001) and hair loss (P < 0.001) were significantly more common. Conclusions LP was not significantly related to HCV infection. Prevalence of pruritus, dry skin and hair loss was significantly higher in post‐compared with pre‐treated patients. The role of IFN in post‐treatment persistence of skin manifestations needs to be assessed.     

Lichen planus sialadenitis: a mucosal analog of lichen planopilaris and lichen planoporitis

Lichen planus (LP) is the most prevalent dermatological disorder with oral manifestation. Oral lesions comprise a broad spectrum of clinical presentations. We report the case of a 56‐year‐old woman who presented erosive LP on the buccal and lower lip mucosae. Besides typical erosions, small white keratotic papules on an erythematosus background on the lower lip mucosa were observed. Biopsy of lower lip lesions showed an unusual histopathological presentation consisting of a lichenoid inflammation targeted to salivary gland ducts. This is probably a salivary gland analog of lichen planopilaris and lichen planoporitis. Lourenço SV, de Resende ACB, Bologna SB, Simonsen Nico MM. Lichen planus sialadenitis: a mucosal analog of lichen planopilaris and lichen planoporitis.     

Immunoperoxidase evaluation of lichen planus biopsies for hepatitis C virus

Background Lichen planus is a papulosquamous dermatosis which has recently been linked to infection with hepatitis C virus. It is unclear whether or not viral antigens may be present in the cutaneous lesions of lichen planus.
Materials and methods Twenty-five paraffin-embedded samples of glabrous lichen planus were evaluated using immunoperoxidase staining for the presence of hepatitis C virions. Control tissues consisted of hepatitis C-infected hepatic tissue ( n = 2), normal hepatic tissue ( n = 2), normal human skin ( n = 1), and two cutaneous biopsies of lichen planus from persons known to be infected with hepatitis C.
Results The sections of hepatitis C-infected liver tissue stained positive for hepatitis C virions. The 25 biopsies of glabrous lichen planus, the two biopsies of lichen planus from hepatitis C patients, the two sections of normal liver, and the one normal skin sample all failed to take up the stain.
Conclusions Cutaneous lesions of lichen planus are more probably reactive to the underlying infection than a manifestation of skin involvement by this disease. This theory is supported by the histologic findings in a lichenoid drug eruption, which are virtually identical to those of idiopathic lichen planus. Insufficient sensitivity by the immunoperoxidase procedure used is a possible explanation for our results; however, it appears more probable that no virus exists at the sites of cutaneous involvement.     

Systemic isotretinoin treatment of oral and cutaneous lichen planus

Lichen planus of the skin and mucous membranes may be disabling. Severe pruritus or bullous lesions may be incapacitating when they occur while erosive oral lesions may be extremely painful. Various treatment modalities have been attempted including corticosteroids (parenteral, intralesional, and topical) and photochemotherapy. Recent successful therapeutic trials of topical retinoic acid and oral etretinate have been completed. Two patients with cutaneous and severe erosive oral lichen planus unresponsive to conventional therapies responded to a trial of oral isotretinoin with prompt and successful remission of cutaneous and oral lesions. This suggests that systemic isotretinoin may have a unique position in the treatment of mucous membrane lichen planus that is refractory to conventional therapies.     

Clinical and Histopathologic Analysis of the Relationship between Lichen Planus and Chronic Hepatitis C

A prospective clinical investigation of 45 patients with lichen planus (LP) demonstrated a significant association between LP and chronic hepatitis C. Anti-hepatitis C virus (HCV) antibodies were found in 17 (37.8%) of the 45 LP patients. This was significantly higher than in the controls. This higher prevalence of anti-HCV antibodies was found equally in both male and female patients in the three types of LP; cutaneous only type, mucous only type, and both cutaneous and mucous type. Most of the patients with positive anti-HCV antibodies had abnormal values of transaminase enzymes and/or a past history of chronic hepatitis. Histological and immunohistological investigations of three cases with LP and chronic hepatitis C demonstrated some morphologic similarities between these two diseases. Histopathologic findings of both LP and chronic hepatitis C were based on a T lymphocytic infiltrate with keratinocyte or hepatocyte damage. The degrees of infiltrating cells positive to UCHL-1, MX-panB, Leu-7, and human leukocyte antigen (HLA)-DR antibodies in the chronic hepatitis C lesions seemed to be similar to those in the LP lesions. These results may support a possible relationship between LP and chronic hepatitis C and the hypothesis that LP may be associated with chronic liver diseases as a result of a cytotoxic attack on the hepatocytes.     

The period prevalence of oral lichen planus in a cohort of patients with vulvar lichen sclerosus

Background Lichen sclerosus and lichen planus are chronic inflammatory mucocutaneous disorders that may coexist. Objective The aim of this study was to estimate the period prevalence of oral lichen planus in a cohort of patients with vulvar lichen sclerosus and to document their clinical characteristics. Methods We report a series of cases of vulvar lichen sclerosus presenting to two dermatologist‐led vulvar clinics in Oxfordshire, England between 1997 and 2007 with coexistent clinical signs of oral lichen planus. Results Thirteen cases with coexistent vulvar lichen sclerosus and oral lichen planus were identified, of which five had oral biopsies. Four oral biopsies showed histological features consistent with lichen planus. One oral biopsy was not diagnostic but compatible with oral lichen planus. No cases of oral lichen sclerosus were identified. The period prevalence of oral lichen planus was 6 per 1000 cases of vulvar lichen sclerosus. Conclusion The period prevalence of oral lichen planus in women with vulvar lichen sclerosus (0.6%) is similar to that reported for oral lichen planus in the general population (1–2%).