Painful Oral Erosions and White Patches

Case Report

A 55-year-old man presented with painful, burning sores in his mouth for several weeks,

Lichen planus before treatment


aggravated by eating spicy foods and caffeine-containing drinks.  Examination showed multiple irregularly shaped erosions with yellow bases and a few white circular areas on the inside of both cheeks (the buccal mucosae).  An oral biopsy confirmed the diagnosis of erosive lichen planus.  He was treated with a medium-strength topical steroid gel called fluocinonide twice daily for two weeks.

At the follow-up visit, he complained that his symptoms were worse.  The mucous membranes now demonstrated white raised patches that could be wiped away by the examiner to reveal bases with bleeding points.  Microscopic examination of the surface cells also showed many pseudohyphae indicative of a yeast infection or thrush.  A culture of this material later grew Candida albicans yeast.  The steroid gel was stopped, and he was asked to take clotrimazole lozenges to dissolve in his mouth five times daily for two weeks.

Candida infection 2 weeks after steroid gel treatment

Candida infection resolved after 2 weeks of clotrimazole lozenge treatment

At the next follow-up visit, his mouth felt completely normal, and the examination showed that his mucous membranes were virtually clear.  No further treatment was given.

 

 

Comment

Oral lichen planus is frequently colonized by yeast organisms such as Candida species.  When steroid medicines such as topical gels , rinses, and pills are used to reduce the inflammation caused by the lichen planus disease, the local immunity is suppressed.  This allows further growth of yeast colonies, invasion of the superficial layer of the mucous membrane, and development of a true yeast infection called “thrush” in the mouth.

What we have learned from this experience is to either treat the presumed yeast infection first, or to combine the anti-yeast and anti-inflammatory steroid treatment from the outset.  We do this routinely now by alternating the oral rinses dexamethasone which is the steroid with nystatin which is the anti-yeast agent with fairly successful results.  There are other choices of steroids and anti-yeast agents available as well as non-steroidal medications for the more resistant cases of oral erosive lichen planus.

Other Interesting Case Studies:
How Efficient Is Your Dermatologist? Example from My Practice-Eczema or Ringworm
Importance of the Second Opinion: Editorial with Illustrative Cases

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2 Responses to Painful Oral Erosions and White Patches

  1. Christine Samples says:

    Hello, I am an RN with a seronegative RA, for which I have opted not to take meds for at this time, given I have joint pain, but no deterioration per films. I have had an elevated sed rate, and CRP, but nothing sky high. Interestingly my rheumatologist had me take a steroid taper in August to see if I had any major improvement with my arthritis symptoms, shortly after that, I developed what I thought was thrush, and did a 2 week round of nystatin, which only slowly improved my symptoms. I redeveloped the Thrush symptoms again in about a month, and repeated they nystatin. Upon the third go round I contact my pcp, as my Rheumatologist is on medical leave, and he gave me Diflucan orally, which has done zero to improve my oral issues.

    I stumbled across this Lichen Planus thing trying to do some research as to what else might be going on, and think I most likey have it. I have had several episodes in the past decade of large painful sores on the roof of my mouth, I have been seen in the UC for it, and they called it shingles (???) My PCP saw it, and said it was probably a form of herpes, but now again I have these erosions on the roof of my mouth, and now this white coating on my tounge. I have also started to take acidophillous in hopes of curing any Candida issues.

    Now my question to you is, who do I go see to get a diagnosis? A dentist? An ENT? or a Derm? I’m quite tired of my mouth being sore, and dealing with this dry mouth, white tounge thing. I’m also not a fan of taking lots of medications, but dang this is getting old.

    I appreciate any feedback or recommendations.

    • DrCamisa says:

      Thank you for your letter. Lichen planus can be diagnosed by an oral biopsy which can be performed by an oral surgeon, ENT doctor, or dermatologist who has an interest in oral diseases. Biopsies of the palate are a lttle more complicated technically. Most general dentists do not perform biopsies. A second biopsy should be performed at the same time for direct immunofluorescence testing because the results can rule out other autoimmune diseases such as lupus and Sjogren’s (dry mouth, dry eyes) syndrome which may be associated with rheumatoid arthritis.

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