Oral Lichen Planus: An Emerging Paradoxical Adverse Effect Of Anti-TNF-α Therapy

Abstract

Introduction: The efficacy of anti-tumor necrosis factor alpha (TNF-α) inhibitors in the treatment of inflammatory bowel disease (IBD) is well established. The increasing use of these agents in clinical practice has led to the recognition of several adverse events, some of them being considered as paradoxical. Many skin and mucosal lesions have been described under anti-TNF-α therapy, including lichenoid reactions. Case Report: The authors present 3 cases of oral lichen planus (OLP) in 3 female patients with IBD (2 with Crohn’s disease and 1 with ulcerative colitis) treated with infliximab (2 patients) and adalimumab (1 patient). A few weeks after starting anti-TNF- α therapy, the patients complained about oral burning pain and significant limitation of food intake and speech. On examination, they had white, reticular lesions in the buccal mucosa and soft palate (Figure 1). The lichenoid origin of the lesions was confirmed histologically (Figure 2). Other etiologies were excluded. Despite the treatment, it was necessary to discontinue anti-TNF-α therapy in 2 patients due to persistent lesions and symptoms.Figure 1Figure 2Discussion: To our knowledge, there are 11 reported cases of OLP due to anti-TNF-α therapy. The development of these lesions appears to result from immunological mechanisms that disrupt the delicate balance between TNF-α and interferon-α in susceptible patients. The treatment and malignant potential of these lesions remains controversial. In light of the increasing use of TNF-α inhibitors, the occurrence of OLP is a potentially emerging side effect; thus, we recommend a thorough oral examination as a routine component of gastroenterologists’ evaluation.