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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 25  |  Issue : 1  |  Page : 6-13

Clinico-epidemiological factors related to lichen planus and its clinical variants at a tertiary care hospital: A descriptive study


Department of Skin and VD, Topiwala National Medical College and B.Y.L. Nair Ch. Hospital, Mumbai, Maharashtra, India

Date of Submission21-Oct-2019
Date of Acceptance25-Jun-2020
Date of Web Publication04-May-2021

Correspondence Address:
Dr. Ankit Gupta
OPD No. 2-37, 2nd Floor, OPD Building, Nair Hospital, Mumbai Central, Mumbai - 400 008, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdds.jdds_66_19

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  Abstract 


Background: Lichen planus (LP) is an immune_mediated, chronic inflammatory disease involving skin, oral and genital mucosa, nails, and hair with several morphologic variants. The exact etiology remains unclear, but several factors have been implicated. Purpose: To study the clinico-epidemiological profile of patients of LP and its clinical variants and to find out whether LP is relatively uncommon in children. Methods: This prospective, cross-sectional, descriptive, time-bound, clinico-epidemiological study was conducted in the outpatient department of dermatology at a tertiary care hospital during the period of June 2017 to October 2018. A total of 170 patients were included in the study. Microsoft Excel and SPSS 23 software packages were used for data entry and statistical analysis. The results were averaged for each parameter for continuous data and numbers and percentage for categorical data. Statistical tests were applied wherever necessary. Results: The overall prevalence of LP was 0.4% (n = 170) out of 42,127 patients who attended the OPD during the study period. The gender-wise prevalence of LP was 41% among females and 59% among males, and the difference was not statistically significant (P = 0.3). The male-to-female ratio was 1.5:1. The highest prevalence among the variants of LP was of classical form (29%) and lowest was of inverse LP (0.6%). Overall, the mean age of the patients was 36 years, with a standard deviation of 17. There was one instance of LP occurring in both father and son. Conclusion: The most common age group of LP was 18 -40 years. Most patients came to seek health care within 1 year of beginning of disease. More than one variant of LP can coexist in the same individual. Childhood LP is not uncommon in the Indian subcontinent.

Keywords: Lichen planus, metabolic syndrome, prevalence


How to cite this article:
Gupta A, Nayak CS. Clinico-epidemiological factors related to lichen planus and its clinical variants at a tertiary care hospital: A descriptive study. J Dermatol Dermatol Surg 2021;25:6-13

How to cite this URL:
Gupta A, Nayak CS. Clinico-epidemiological factors related to lichen planus and its clinical variants at a tertiary care hospital: A descriptive study. J Dermatol Dermatol Surg [serial online] 2021 [cited 2021 May 12];25:6-13. Available from: https://www.jddsjournal.org/text.asp?2021/25/1/6/315334




  Introduction Top


Lichen planus (LP) is an immune-mediated, chronic inflammatory disease involving skin, oral and genital mucosa, nails, and hair with several morphologic variants. The exact etiology remains unclear, but several factors have been implicated including infectious, genetic, autoimmune, and psychogenic factors. LP has worldwide distribution, and studies have shown that the prevalence ranges from 0.8% to 2.6%.[1] A slight female predilection has been reported.[2] Nail involvement is seen in around 1% to 10% of patients although nail LP as a sole manifestation of the disease is rare.[3] Oral LP is considered to be a premalignant disorder, and the rate of malignant transformation ranges from 0.5% to 2%.[4] LP is usually self-limited and may resolve over a period of a few weeks to years. This occurs on an average of 18 months with residual post-inflammatory hyperpigmentation. Childhood LP is relatively uncommon, and mucosal involvement in children is rare. There is scarcity of studies in literature on various morphologic variants of LP in children. Our study presents the clinico-epidemiological profile of patients of LP and its clinical variants including children.


  Methods Top


This prospective, cross-sectional, descriptive, clinico- epidemiological study was conducted in the outpatient department of dermatology at a tertiary care hospital. Approval was obtained from the institutional ethics committee during the period of June 2017 to October 2018.

A total of 170 patients were included in our study.

Patients presenting with a clinical diagnosis of LP or its variants of all age groups and those willing to give consent for photography and skin biopsy were included.

Patients with LP and not willing to give consent were excluded.

Demographic details including age, gender, onset, duration and progression of disease, detailed information about aggravating and relieving factors, associated medical and skin conditions, treatment history, family history, personal history, illicit drug use, alcohol use, tobacco use, and diet history were recorded. History of sun exposure, drug intake prior to appearance of lesion, and any irritant application were taken. Clinical examination (including oral and genital) findings were recorded, and clinical photographs were taken. Biopsy was performed wherever needed and the specimen was subjected to conventional hematoxylin and eosin staining in our department only.


  Results Top


One hundred and seventy patients were enrolled in the study from June 2017 to October 2018. The gender-wise prevalence of LP was 41% among females and 59% among males, and the difference was not statistically significant (P = 0.3). The prevalence of LP was 0.4% and did not differ statistically significantly in different age groups (P = 0.95) [Table 1]. Classical LP had the highest prevalence (0.12%) and inverse LP (0.002%) had the lowest prevalence. The mean age of the patients was 36 years, with a standard deviation of 17. Among males, the mean age was 37 years, which was comparable with 35 years among females, and this difference was not statistically significant (P = 0.92).
Table 1: Types of lichen planus (all age groups)

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Among patients with LP, there were 101 (59%) males and 69 (41%) females, thus the male-to-female ratio was 1.5:1 [Table 2]. Among children, 16 (57%) out of 28 were male and 12 (43%) were female. The male-to-female ratio was 1.3:1. The majority of the patients, 82 (48%), belonged to the age group of 18–40 years (second and fourth decades).
Table 2: Types of lichen planus (children)

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Among patients with LP, the most common variant of LP overall was the classical type in 50 (29%) patients followed by mucosal in 25 (15%) patients [Table 3] [Figure 1]. The least common type was inverse LP in one (0.7%) patient [Figure 2]. More than one variant of LP in the same individual were seen in 12 6.9%) patients [Figure 3].
Figure 1: Multiple violaceous flat-topped polygonal papules present on the dorsum of both the hands with koebnerization (classic lichen planus)

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Figure 2: Multiple violaceous to hyperpigmented papules with few coalescing to form plaques on the groin (inverse lichen planus)

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Figure 3: Occurrence of different variants of lichen planus in all age groups

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Table 3: Types of lichen planus (18-40 years)

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Among children (<18 years), the most common variant of LP was classical LP in 12 (43%) patients, followed by guttate in five (18%) patients [Figure 4].
Figure 4: Occurrence of different variants of lichen planus in children

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In patients aged 18–40 years, the most common variant of LP was classical LP in 20 (24%) patients, followed by LP pigmentosus in 16 (20%) patients [Figure 5] and [Figure 6].
Figure 5: Occurrence of different variants of lichen planus in 18–40 years of age

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Figure 6: Hyperpigmented to violaceous patches present on periocular area of both the eyes (lichen planus pigmentosus)

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In 41–60 years' age group, the most common variant of LP was classical LP in 12 (26%) patients, followed by hypertrophic in 10 (22%) patients [Figure 7] and [Figure 8] [Table 4].
Figure 7: Occurrence of different variants of lichen planus in 40–60 years of age

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Figure 8: Single, well-defined hypertrophic plaque with few keratotic papules on the surface and depigmentation at one end (hypertrophic lichen planus with steroid-induced depigmentation)

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Table 4: Types of lichen planus (41-60 years)

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In patients older than 60 years, the most common variant of LP was classical LP in six (43%) patients, followed by mucosal in three (21%) and the least common type was guttate LP in one (7.2%) patient [Figure 9] [Table 5].
Figure 9: Occurrence of different variants of lichen planus in >60 years of age

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Table 5: Types of lichen planus (>60 years)

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Two or more variants of LP can coexist and were found in 12 (7.1%) patients in this study, with the occurrence of classical type of LP along with mucosal LP being the most common among them [Figure 10].
Figure 10: Simultaneous occurrence of >1 variant of lichen planus (all age groups)

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In this study, involvement of oral mucosa was present in 32 (89%) cases followed by genital and both mucosal involvement in two (5.5%) cases each.

In the oral cavity, buccal mucosa was involved in 28 (82%) cases followed by lips in two (6%), lateral margin of tongue in one (3%), and involvement of two or more parts of oral cavity in three (9%) cases. [Figure 11]
Figure 11: Whitish thickened plaque on the left buccal mucosa (oral lichen planus, plaque type)

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Among patients with oral LP, the reticular type in 16 (47%) patients was the most common followed by plaque like in 14 (41%) and erosive in four (12%) patients [Figure 12] and [Figure 13].
Figure 12: Whitish plaque with lacy pattern on the right buccal mucosa (oral lichen planus, reticulate type)

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Figure 13: Multiple erosions on the left buccal mucosa (oral lichen planus, erosive type)

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In cases of genital involvement in males, the glans penis was involved more often than prepuce and shaft of penis [Figure 14]. In females, vulvar involvement was most frequent than other sites.
Figure 14: Multiple small erythematous to violaceous flat-topped papules present on the glans penis (genital lichen planus)

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Nail LP as a solitary finding is uncommon, with the most common change being longitudinal ridging followed by splitting and dorsal pterygium.


  Discussion Top


Our study showed similar prevalence rates with similar demographics in the study performed by Bhattacharya et al.,[5] with LP being most common in the second to fourth decades.

Of the 36 patients included in the study by Walton et al.,[6] 24 (67%) were female and 12 (33%) were male. There were 125 (53.9%) males and 107 (46.1%) females of a total of 232 patients in Bhattacharya et al.'s[5] study. In the study by Singh and Kanwar,[7] there were 266 males and 175 females, whereas in our study, there were 101 (59%) males and 69 (41%) females. Among children, 16 (57%) out of 28 were male and 12 (43%) were female [Table 6].
Table 6: Simultaneous occurrence of more than one variant in an individual (all age groups)

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The youngest patient was an 8-year-old boy and the oldest was a 76-year-old male in the study by Bhattacharya et al.,[5] whereas in our study, the youngest patient was a 4½-year-old girl and the oldest was a 75-year-old male. [Table 7] shows comparison of demographic data of patients with lichen planus in various studies [Table 7].
Table 7: Comparison of demographic data of patients with lichen planus in various studies

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In our study, lesions of follicular LP were observed on the scalp in all the cases like the study by Bhattacharya et al.,[5] and cicatricial alopecia of the scalp was present in all the patients of follicular LP.[5] Table 8 shows comparison of lichen planus morphology, variants, and distribution among various studies [Table 8].
Table 8: Comparison of lichen planus morphology, variants, and distribution among various studies

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In our study, lesions of linear LP were present in a zosteriform pattern in three patients and as a linear band in one patient [Figure 15]. Bhattacharya et al.[5] found two patterns of linear LP: one patient had zosteriform pattern which was distributed along the neck and the upper chest and another patient presented with linear LP along the length of forearm in the form of a long, narrow, linear band.
Figure 15: Multiple violaceous papules coalescing to form plaques arranged linearly involving C6, 7, and 8 dermatomes (linear lichen planus, zosteriform pattern)

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In our study, oral mucosa was involved in 34 (20%) patients, with reticulate pattern being most common which was observed in 16 (47%) patients and predominantly localized to the buccal mucosae. In the study by Soma Susan Varghese et al.,[9] the most common form of LP was reticulate LP, whereas erosive LP accounted for the second most common cause of oral LP. Erosive LP was the most common cause, observed in twenty (57.1%) patients in a study by Barbosa et al.[10]

In our study, oral erosions were observed in four (12%) patients, whereas 19 (19.6%) patients had oral mucosal erosions in the study by Bhattacharya et al.[5]

Simultaneous skin, oral, and genital mucosal involvement was observed in 12 (5.2%) patients in the study by Bhattacharya et al.[5] In our study, only genital involvement was observed in six (3.5%) patients.

We found only one case of nail pterygium, an unusual finding similar to the study by Bhattacharya et al.[5] [Figure 16]. [Table 9] shows comparison of skin, mucosa, and nail involvement in lichen planus among various studies [Table 9].
Figure 16: Wing-shaped extension of proximal nail fold over the nail plate involving all the finger nails (nail lichen planus, pterygium formation)

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Table 9: Comparison of skin, mucosa, and nail involvement in lichen planus among various studies

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[Table 10] shows comparison of demographic data of patients with lichen planus in various studies [Table 10]. Earlier, LP in children was considered a rare entity due to lack of studies on childhood LP in literature. Recent studies have described a higher percentage of cases in childhood (10%–11%).[11],[12],[13] [Table 11] shows comparison of lichen planus morphology, variants, and distribution among various studies in children [Table 11].
Table 10: Comparison of demographic data of patients with lichen planus in various studies

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Table 11: Comparison of lichen planus morphology, variants, and distribution among various studies in children

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[Table 12] shows comparison of skin, mucosa, and nail involvement in lichen planus among various studies in children [Table 12].
Table 12: Comparison of skin, mucosa, and nail involvement in lichen planus among various studies in children

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In our study, 19 (11%) patients were taking concomitant medications for medical problems which included anti-diabetics in three, anti-hypertensives in eight, and both anti-diabetics and anti-hypertensives in eight patients, whereas in the study by Bhattacharya et al.,[5] 25 (10.8%) patients had concomitant medical problems for which they were on oral medications which included 16 patients of hypertension. Diabetes mellitus, epilepsy, and angina each was present in three patients who were on treatment. The three patients were taking nonsteroidal anti-inflammatory drugs. Asthma, tuberculosis, and hypothyroidism each was present in two patients.

In our study, no associated cutaneous diseases were found. On comparison, in the study by Bhattacharya et al.,[5] 21 (9.1%) cases had associated cutaneous diseases which included alopecia areata (most common) followed by lichen sclerosus et atrophicus, vitiligo, discoid lupus erythematosus (DLE), DLE with vitiligo, tinea cruris, epidermal nevus, verruca vulgaris, acne vulgaris, and pityriasis versicolor.

In our study, associated systemic diseases were found in 19 (11%) patients with diabetes mellitus in three (1.8%), hypertension in eight (4.7%), and both diabetes mellitus and hypertension in eight (4.7%) patients. In the study by Bhattacharya et al.,[5] systemic diseases were found associated in 38 (16.4%) patients, 10 (4.3%) patients had hypertension, three (1.3%) had diabetes mellitus, and two (0.9%) had both hypertension and diabetes. Other associated systemic diseases which were found in patients with lichen planus in the study by Bhattacharya et al included tuberculosis, bronchial asthma, acid peptic disease (erosive esophagitis/peptic ulcer) and osteoarthritis in two (0.9%) patients each whereas ulcerative colitis, recurrent urinary tract infection, hyperthyroidism, ankylosing spondylitis, migraine, varicose veins, epilepsy and ischemic heart disease in one (0.4%) patient each.

In our study, metabolic syndrome was found in six (3.5%) patients. In the study by Hashba et al.,[15] metabolic syndrome was observed in 25 (35.7%) patients. Panchal et al.[16] found significantly higher levels of total cholesterol, low-density lipoprotein, triglycerides, and reduced levels of high-density lipoprotein in patients of LP [Table 13].
Table 13: Comparison of prevalence of metabolic syndrome in lichen planus among various studies

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Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Walton KE, Bowers EV, Drolet BA, Holland KE. Childhood lichen planus: Demographics of a U. S. population. Pediatr Dermatol 2010;27:34-8.  Back to cited text no. 6
    
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Singh OP, Kanwar AJ. Lichen planus in India: An appraisal of 441 cases. Int J Dermatol 1976;15:752-6.  Back to cited text no. 7
    
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Parihar A, Sharma S, Bhattacharya SN, Singh UR. A clinicopathological study of cutaneous lichen planus. J Dermatol Dermatol Surg 2015;19:21-6.  Back to cited text no. 8
    
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Varghese SS, George GB, Sarojini SB, Vinod S, Mathew P, Mathew DG, et al. Epidemiology of oral lichen planus in a cohort of South Indian population: A retrospective study. J Cancer Prev 2016;21:55-9.  Back to cited text no. 9
    
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Barbosa NG, Silveira ÉJ, Lima EN, Oliveira PT, Soares MS, de Medeiros AM. Factors associated with clinical characteristics and symptoms in a case series of oral lichen planus. Int J Dermatol 2015;54:e1-6.  Back to cited text no. 10
    
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Luis-Montoya P, Domínguez-Soto L, Vega-Memije E. Lichen planus in 24 children with review of the literature. Pediatr Dermatol 2005;22:295-8.  Back to cited text no. 11
    
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Kumar V, Garg BR, Baruah MC, Vasireddi SS. Childhood lichen planus (LP). J Dermatol 1993;20:175-7.  Back to cited text no. 12
    
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Sharma R, Maheshwari V. Childhood lichen planus: A report of fifty cases. Pediatr Dermatol 1999;16:345-8.  Back to cited text no. 13
    
14.
Handa S, Sahoo B. Childhood lichen planus: A study of 87 cases. Int J Dermatol 2002;41:423-7.  Back to cited text no. 14
    
15.
Hashba H, Bifi J, Thyvalappil A, Sridharan R, Sreenivasan A, Mathew P. Prevalence of metabolic syndrome in patients with lichen planus: A cross-sectional study from a tertiary care center. Indian Dermatol Online J 2018;9:304-8.  Back to cited text no. 15
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16.
Panchal FH, Ray S, Munshi RP, Bhalerao SS, Nayak CS. alterations in lipid metabolism and antioxidant status in lichen planus. Indian J Dermatol 2015;60:439-44.  Back to cited text no. 16
[PUBMED]  [Full text]  


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13]



 

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