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American Journal of Advances in Medical Science

www.arnaca.com
Vol-2: No-1: 7-11:2014

Case Report

Successful treatment of Oral Lichen Planus (OLP) with 0.1% topical

Tacrolimus in a patient with impaired liver enzymes: A Case report

Upender malik1*, Siddarth Gupta 2, Shilpa Dutta Malik3 ,

Sanjay Dutta 4
1

Department of oral medicine and radiology, Seema

dental college and hospital, Rishekesh , Uttarkhand,
India.
2
Department of oral medicine and radiology, I.T.S.
Dental College, Hospital and Research Centre, Greater
Noida, Uttar Pradesh, India
1
Department of oral pathology, Seema dental college and
hospital, Rishekesh , Uttarkhand, India
4
Department of oral medicine and radiology, Maharana
Pratap Dental College, Gwalior , Madhy Pradesh, India.

Abstract
In the present case report, a case
of a patient with blisters in oral
cavity which indicate erosive
Oral Lichen Planus ( OLP)
lesions associated with elevated
serum SGOT, SGPT levels along
positive Tri Dot for Hepatitis C
Virus is reported. Outcome of the
present case report suggests that
extensive clinical, laboratory and
microscopic
evaluation
is
necessary to identify the probable
etiology of the condition and to
choose the most appropriate
treatment regimen.

Keywords: Oral Lichen Planus, Tacrolimus

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Introduction
Oral lichen planus (OLP) is a chronic
inflammatory mucocutaneous disorder,
affecting stratified squamous epithelia, with
a prevalence of 0.02% - 1.2% among the
various populations and most commonly
affects the individuals in 5th to 6th decade of
life with a more female preponderance [1].
Intra oral presentation of the lesions is
divided into three forms namely reticular,
atrophic (erythematous), erosive (ulcerative
and bullous) with posterior buccal mucosa
most frequently affected site [2]. Etiological
factors associated shows the role of
psychological stress (high levels of anxiety

& depression), contact hypersensitivity to

dental materials especially to amalgam
herpes viruses (HSV1, EBV, and HHV6),
HIV, HPV, Hepatitis B virus, most recently
role of hepatitis C virus is also stressed on
as an etiological factor in Oral Lichen
Planus [3]. In recent years, an association
between OLP and HCV has been described
in populations from Japan and some
Mediterranean countries. It has been
postulated that the association may be
related to a genetic variability; however no
comprehensive explanation has been
provided regarding this association [4].

Figure-1: Presence of extensive

erosive lesions involving left buccal mucosa

Figure-2: Large bullous lesion present on

floor of the mouth

The pathogenesis of oral lichen planus

although chiefly unknown, a large body of
evidence supports a role of immune
dysregulation. As per the current state
multiple topical and systemic treatments for
the oral lichen planus have been reported to
be effective and includes corticosteroids,
both topical and systemic, retinoids,
ultraviolet phototherapy (PUVA), steroid
sparing
agents
(hydroxychlorquione,
azathioprine, mycophenolate mofetil) and
pimecrolimus. Although above mentioned

drugs showed positive results in the

treatment of oral lichen planus but a
resistant to treatment and a high risk of
toxicities limit their use [5]. Although these
drugs showed positive results in the
treatment of oral lichen planus but a
resistant to treatment and a high risk of
toxicities limit their use [6]. Tacrolimus is a
novel immunosuppressant which has
recently been shown to be effective and safe
in the treatment of symptomatic oral lichen
planus. Tacrolimus is 10-100 times more

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potent than cyclosporine in its ability to

inhibit IL-2 mRNA synthesis and inhibits
mediator release from basophils and mast
cells. It inhibits enzyme calicneurin
phosphatase activity resulting in decrease in
IL-2 synthesis and secretion, hence
inhibiting T- cell multiplication.
In this case report use of 0.1% tacrolimus
as a topical therapy in treating oral lichen
planus lesions in a patient with raised
SGOT , SGPT levels along with positive Tri
Dot for Hepatitis C virus has been
portrayed.
Case report
A twenty-eight years female patient
reported with a complaint of blisters
throughout the mouth with associated
difficulty in eating salty and spicy food for

past two weeks. Patient didnt give history

of any systemic disease or any previous
episodes of similar blisters in past. On intra
oral examination of the patient ulcerations
were present throughout the oral cavity
involving the buccal mucosa, labial mucosa,
dorsal and ventral portions of the tongue
mucosa and mucosa of the floor of the
mouth. (Figure-1, figure-2)A provisional
diagnosis of ulcerative oral lichen planus
was made and patient was sent for routine
blood examination along with SGOT, SGPT
and Tridot test for Hepatitis C virus. The
blood examination report revealed higher
values of SGOT and SGPT along with a
positive Tridot test for Hepatitis C virus
infection.

Figure-3:Histopathological features depicting

hyperparakeratosis, saw tooth appearance of rete ridges

Figure-4: Post treatment completely healed

lesion

Histopathologically, the lesions were

confirmed to be of bullous oral lichen
planus. (figure-3).
Tacrolimus powder
(Courtesy Ranbaxy, Gurgaon, India) was
mixed keeping
Oraguard-B (purchased
from Colgate Palmolive, U.S.A) as base in
such a way as to get a concentration of 0.1%
tacrolimus powder with base7. Patient was
given the medication to be applied topically
three times daily for a period of 15 days.
The patient was instructed not to eat or rinse
the mouth after application of the ointment

for half an hour. Recalled appointments

were kept at an interval of 15 days to assess
the response to the treatment and to
reinforce the instructions.
At first recall assessment, marked
improvement of the signs and symptoms
were observed and patient reported a
marked decrease in pain and burning on
eating. Within two months of the treatment
a complete response to treatment in the form
of completely healed lesions were observed
along with complete resolution of pain and

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burning. (figure-4). he medication was

discontinued and patient was kept under
observation, after one month of stopping the
medication lesions recurred but were very
mild in intensity. Patient remained totally
asymptomatic during the period of one
month post therapy and even after the
recurrence; patient didnt give any history of
discomfort as previously reported.
Discussion
Lichen planus is a mucocutaneous disease
characterized by a cellular inflammatory
infiltrate enriched in CD4+cells, by the
presence of acidophilic bodies that may
represent apoptotic epithelial cells, and by
vacuolating degeneration of the basal
epithelial layer. Recently, positive and
negative HCV RNA strands were detected
in epithelial cells of the normal oral mucosa
and in lesional tissue of oral LP from antiHCV positive patients by both strandspecific reverse-transcription polymerase
chain reaction (RT-PCR) and in situ
hybridization [7]. Association of HCV
infection with different extra-hepatic
manifestations has been described but the
pathogenetic role of HCV in the

development
of
these
extra-hepatic
manifestations is undefined. HCV specific
CD4+ and CD8+ cells are present within
intralesional infiltrates in oral lichen planus
associated with chronic HCV infection [8].
These cells are specifically recruited into the
oral lesions because there frequency has
always been higher than in peripheral blood
[9,10]. In our case patient presented with
elevated SGOT, SGPT and positive Tridot
test for Hepatitis C virus. Due to these
hepatic manifestations, the use of systemic
agents was contraindicated, so topical agent
proven to be effective, safe and with no
reported side effect was chosen.
Conclusion
A variety of systemic conditions may be
associated with lesions of Oral Lichen
Planus and at times oral manifestations are
the only signs and symptoms present in lieu
for the underlying condition as seen in our
patient. Hence, an extensive clinical,
laboratory and microscopic evaluation is
mandatory to identify the probable etiology
of the condition and to choose the most
appropriate treatment regimen.

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