Oral bullous lichen planus: Case report and review of management
A 34-year-old Indian female patient reported to the Department of Oral Medicine and Radiology with the chief complaint of burning sensation of oral cavity since 4 days. Burning sensation was insidious in onset, preceded by eruption of fluid filled vesicles that used to burst within few seconds, continuous, severe intensity aggravated on having spicy food substances and no relieving factors, episodes of such occurrence of blisters 10-15 times per day. She was also associated with generalized body itching and mild fever. History of recurrent episodes of burning sensation since 8 years but this time associated with severity. Her medical history revealed occurrence of dermal and scalp lesions, loss of hair, generalized pruritis for which she was taking treatment by a dermatologist since 10 years and presently was on the following medications: pimecrolimus (pacroma cream 0.01%), halobresol propionate cream (halox cream 0.05%), and ketoconazole shampoo (Keto Az shampoo). History of anal hemorrhoids treated 4 years back. Her past dental history revealed that extraction of mobile teeth and gingival flap surgery was done 8 years back.\nNo significant family history. She was married since 13 years blessed with two children (girls) and stays in a joint family, often her life was associated with stress and tension as reported by the patient. Vegetarian by diet. No history of any deleterious habits. She brushed once daily in horizontal manner using brush and paste. General physical examination revealed that she is moderately built and nourished, appeared depressed and sad. Depression Anxiety and Stress Scale [DASS] score indicated moderate depression, mild anxiety, and moderate stress. Scalp had isolated central area of hair loss, solitary ulcerative lesion measuring about 3 ×4 cm, margins were irregular, floor covered with yellow slough, tender on palpation. Nails present with mild longitudinal ridging. Black healed pigmented lesions of varying sizes were evident on legs, hands, and back [].\nOn intra-oral examination solitary mixed red and white lesions, irregular in shape, measuring about 2 ×3 cm i.r.t right posterior buccal mucosa extending anteriorly from mesial of 45 posteriorly distal to 48, superiorly from occlusal plane of 14 inferiorly up to buccal vestibule i.r.t 45 46 47 48 regions, surface presented with bullae filled with clear fluid measuring about 1 ×0.8 cm, margins are irregular with pseudo membrane slough in the posterior buccal mucosal region, surrounding buccal mucosa was normal [].\nLeft buccal mucosa presented with solitary red and white lesion measuring about 3 × 3.5 cm irregular in shape, extending along the line of occlusion extending supero-inferiorly about 1 cm on either side, has central area of erythema surrounded surface by white striae [].\nHard palate showed solitary white lesion measuring about 1.5 ×1 cm irregular in shape, extending anteriorly from mid-palatal raphe posteriorly to line joining distal surface of 13 23, white papules, interspersed with striae, surrounding mucosa was normal.\nOn palpation inspectory findings were confirmed as tender, smooth, and nonscrappable.\nGingiva was observed with generalized gingival inflammation, erythematous, bleeding on probing, tender, lower right side of posterior gingiva had typical white striae. Generalized pockets were present. Hard tissue examination reveals teeth 15 14 13 12 11 21 22 23 3 24 25 27 48 47 46 45 44 43 42 41 31 32 33 34 35 38. 38 – Grade III mobility. Considering history and clinical features Bullous lichen planus (LP) was considered as provisional diagnosis with the differential diagnosis phemphigus vulgaris, Bullous phemphigoid, mucus membrane phemphigoid, Lichenoid contact stomatitis.\nPatient was subjected to investigations like orthopantomogram (OPG), complete hemogram, blood sugar, cytosmear, and incisional biopsy from right buccal mucosa. All laboratory findings were within normal limits, and biopsy confirmed as LP, which showed typical histopathological features.\nShe was treated with Tab levamisole (Vermisol) 150 mg once daily for 3 days, Tab prednisolone (Wysolone) 10 mg 4 times a day for 10 days, benzydamine oral rinse 0.15% (Tantum oral rinse), ranitidine 150 mg (Histac EVT) once daily for 10 days. On second visit after 10 days, patient reported with 50% reduction in burning sensation and also episodes of occurrence of bullae was reduced from 10–15 times/day to 7–8 times/day. The dose of wysolone was tapered. On third visit after 15 days patient reported with complete reduction of burning sensation and was enjoying the taste of food. Episodes of bullae occurrence was 4 times in 15 days. On fourth visit after 15 days lesions on right and left buccal mucosa had healed for remaining white lesions, triamcinolone (caziq) was prescribed for topical application. On fifth visit her lesions on right and left buccal mucosa had healed, her scalp lesions too were healed and erythematous gingiva was much reduced []. Patient was referred to Department of Periodontics for oral hygiene prophylaxis. Patient is still under follow up since a year and free of lesions.