Oral Erosive Lichen Planus Treated With Efalizumab

Abstract

A 54-year-old white woman presented with a 3-month history of progressive painful lesions on her tongue and oral mucosa. Her primary care physician initially treated her with nystatin and hydrogen peroxide, followed a few weeks later by acyclovir (Zovirax) ointment and a rapid 5-day prednisone taper, without improvement in her symptoms. Two months after the oral lesions developed, violaceous papules began to appear on her body as well. The week before presentation, she complained of difficulty in swallowing pills because of the pain associated with her oral lesions. She did not have a history of liver disease or hepatitis. A review of systems revealed no recent weight changes, fevers, or chills, and except for the symptoms mentioned above, the findings were otherwise unremarkable. Physical examination demonstrated excoriated erythematous papules and plaques on the bilateral aspect of the arms and on the chest, back, and lower extremities, a few of which appeared violaceous. Oral erosions were present on the tongue, lips, and buccal mucosa (Figure 1), as was an erosive gingivitis. The neck, eyes and eyelids, abdomen, digits, and nails were otherwise normal in appearance. The initial differential diagnosis included oral erosive lichen planus with cutaneous lichen planus as well as cicatricial pemphigoid and pemphigus vulgaris, which were less likely. Two 4-mm punch biopsy specimens were obtained: one was sent for hematoxylin-eosin staining and the other for direct immunofluorescence. A serum sample was also obtained for indirect immunoflourescence. The patient was started on a regimen of prednisone (60 mg/d tapered over 18 days) and topical tacrolimus ointment (twice daily) for the oral lesions. Laboratory tests revealed a low positive antinuclear antibody titer ( 1:40) and a slightly low platelet count (128 10/μL), but the hematocrit, erythrocyte sedimetation rate, complete metabolic profile, and thyrotropin level were normal. Histopathologic examination revealed a lichenoid dermatitis with abundant colloid bodies, which was highlighted by IgG, IgM, and C3 on direct immunofluorescence, findings that were consistent with lichen planus. There were no other abnormalities noted on direct or indirect immunofluorescence. After the steroid taper, the patient experienced a slight (approximately 33%) improvement of the oral lesions, but the painful oral erosions and gingivitis persisted despite the continuation of topical tacrolimus therapy.