Lichen planus and urethral syndrome

Q-I have a patient who has been afflicted with lichen planus for more than 20 years, affecting mainly the mouth. The condition is now much worse than it was 20 years ago and conventional medicine can only offer

palliatives. Is there a cure, and what alternative approaches may help? The patient is near desperation. RF, dental surgeon, Hertfordshire........

A-Lichen planus is a chronic inflammatory disease that is often painful and annoying. It affects up to two per cent of the population, and a typical patient tends to be over 50 years old, well educated, anxious and highly strung. Many patients have also experienced very stressful events in their lives (Gen Dent, 1997; 45: 126-32). It affects one third as many women as men.

It usually concentrates in the mouth, but can also be found in the scalp and nails. Sometimes it causes disfiguring skin lesions, and medical practitioners need to be on the alert in case they are precancerous, although a link with cancer has not been definitively proven (Br J Oral Maxillofac Surg, 2000; 38: 370-7).

The fact that your patient has been a sufferer for 20 years suggests that she has mucosal lichen planus rather than the more benign cutaneous lichen planus, which usually resolves itself within two years (Clin Exp Dermatol, 2000; 25: 176-82).

It is worth exploring likely causes as this may provide the key to a cure, or at least an improvement. Many possible triggers have been suggested, but an assessment of the profile of a typical patient indicates that the disease is linked to stress which, in turn, affects immune function.

Researchers are beginning to narrow down the likely causes, which include the use of conventional drugs such as antimalarials, penicillin, thiazide diuretics, beta blockers and NSAIDs (non steroidal anti inflammatory drugs), quinidine and ACE inhibitors (Am Fam Physician, 2000; 61: 3319-24).

Dental materials can also be a cause. Dentists who have substituted amalgam fillings for gold have often caused a remission of the disease, so it is important to check for sensitivity to gold as this may be another cause (Ned Tijdschr Tandheelkd, 2000; 107: 198-202).

Links to liver disease and the hepatitis C virus have been mooted, and is a relatively new area of research (Crit Rev Oral Biol Med, 1998; 9: 86-122; J Med Virol, 2001; 64: 183-9). Patients with diseases of the mouth mucosa are often deficient in zinc and vitamin A (Mund Kiefer Gesichtschir, 1998; 2: 320-5), so high dose supplements may be helpful.

Conventional treatment tends to be palliative, although it is fair to say that some patients have responded better to such treatment than others. In a meta analysis of conventional treatments, the most common and most effective appeared to be strong topical corticosteroids; topical cyclosporin is sometimes tried as a second line treatment if the corticosteroids don't have any effect. But classical PUVA (psoralen ultraviolet A) therapy has too many side effects, researchers warn (Oral Dis, 1999; 5: 196-205).

Treatment with antimalarials and azathioprine helped two sufferers, a surprising remedy as other researchers suspect antimalarials as being a possible cause (Br J Dermatol, 2001; 144: 1219-23).

A woman who had lichen planus of the lower lip for 11 years found her condition improved dramatically with chloroquine phosphate within three months, after years of unsuccessful treatment with oral and topical drugs (Dermatology, 1997; 195: 284-5).

An alternative to topical steroids, particularly if a large area of the mouth has to be covered, is a mouthwash solution. Nearly half of 54 lichen planus patients who tried an aqueous hydrocortisone mouthwash found a great improvement in their condition, possibly because they had been unable to apply the cream properly (Acta Odontol Scand, 1998; 56: 157-60).

One approach that has had some success, but limited usage, is CO2 laser therapy under local anaesthesia. In a trial of 10 patients, it successfully cleared all lesions and the patients remained well at a three year follow up (J Clin Laser Med Surg, 1992; 10: 445-9).

However, there was a less successful trial involving 29 sufferers. Of these, 16 reported a recurrence of lesions within a year, and a similar number felt slight to moderate pain during treatment (Acta Otorhinolaringol Esp, 1999; 50: 543-7).

One drug being tested apparently with some success is thalidomide, although how many practitioners will be able to convince their patients to try it is another matter (Arch Dermatol, 2000; 136: 1442-3).

Turning to alternative treatments, there is little that has been the subject of a trial. One that has is the gargle Koukangning, based on a Traditional Chinese remedy. It was tested against a placebo, and helped the condition within three to six days. Researchers point out that the gargle is non toxic, and is an excellent anti inflammatory and antibiotic (Hua Xin Kou Qiang Yi Xue Za Zhi, 1997; 15: 28-30).

There is also a reported case in which aloe vera helped the condition (Gen Dent, 1999; 47: 268-72). Also, a reasonable amount of evidence suggests that peppermint oil (Mentha piperita) can help in cases of inflammation of oral mucosa, and is available in Germany as an over the counter remedy for this. Peppermint oil has antibacterial properties, as do many essential oils. The oil is also approved by ESCOP (European Scientific Cooperative in Phytotherapy) for skin conditions such as pruritus (intense itching) and hives.

Overall, treatment is hit and miss and can be long term. As steroids are the drug of choice, practitioners need to watch for any side-effects caused by lengthy use. Although most researchers concede that conventional treatment is, at best, palliative, a report from the University of California, San Francisco suggests this is due to improper diagnosis at the outset, and recommends that a biopsy be done before any therapy is started (Semin Cutan Med Surg, 1997; 16: 295-300).