Case #24 Discussion

Summary: The patient has vesicular-ulcerated-erythematous lesions consisting of:   ~Persistent multiple painful ulcers   ~Tender erythematous mucosa   ~White surface lesions. The patient also has ulcers and crusts of the skin. Lesions to Exclude from the Differential Diagnosis: Hereditary   ~Epidermolysis Bullosa *Begin at birth or early childhood. Viral infections   ~Have acute onset and resolution with cervical lymphadenopathy. Idiopathic Diseases   ~Aphthous Ulcers *Lesions have acute or abrupt onset and heal.   ~Erythema Multiforme *Acute onset with healing   ~Epithelial Dysplasia, Carcinoma-in-situ, and squamous cell carcinoma *Typically not as persistently painful   ~Contact stomatitis *No history of contact with cinnamon, dentifrices, mouthrinses or other agents that commonly cause this. Lesions to Include in the Differential Diagnosis: Candidosis   ~White plaques which rub off leaving a tender base Lichen Planus   ~Lacy line pattern of white epithlelial thickening   ~Multiple ulcers are often present in lichen planus.   ~Skin lesions typical of lichen planus are present Lupus Erythematosus   ~Can have painful oral mucosal ulcers   ~Lupus erythematous may have skin lesions similar to this patient. Management: Since Candidosis is in the differential diagnosis, attempt to treat this first with antifungal agents to help arrive at a definitive diagnosis.  The antifungal medications resolved some of the lesions.  An incisional biopsy of the white thickened lesions was performed and diagnosed as lichen planus.  The patient was educated about the nature of lichen planus emphasizing that the disease can be controlled with steroid medication but not cured.  A topical steroid mouthrinse should be attempted initially.  Candidosis is a common complication of lichen planus and needs to be treated with antifungal medication when it occurs.        Final Diagnosis: Lichen planus of oral mucosa and skin and candidosis