A 46-year-old man comes to the office due to discomfort in his mouth. For the last several months, he has had a mild, but increasingly bothersome, burning sensation on the inside of his cheeks and back of his mouth. The symptoms are worse when the patient eats hot or spicy foods or speaks for extended periods. Examination findings are shown in the exhibit. Which of the following is the most likely diagnosis?

Question

A 46-year-old man comes to the office due to discomfort in his mouth.  For the last several months, he has had a mild, but increasingly bothersome, burning sensation on the inside of his cheeks and back of his mouth.  The symptoms are worse when the patient eats hot or spicy foods or speaks for extended periods.  Examination findings are shown in the exhibit.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d380_71ff_bc81_d3afe964c400_MD0003_00 This patient has chronic papules involving the oral mucosa consistent with lichen planus (LP). LP is an autoimmune disorder driven by CD8⁺ T cells and may occur after exposure to a trigger, such as an infection, a medication, or a contact allergen. LP occurs in a higher frequency in patients with hepatitis C, although the relevance of this association is controversial. Oral manifestations of LP may occur alone or in association with skin or genital lesions. Unlike cutaneous LP (eg, pruritic purple/pink polygonal papules), oral LP lesions are most commonly characterized by white papules or plaques connected by white, lacy markings known as Wickham striae; erythematous mucosal atrophy or ulcerations can also occur. Lesions are typically bilateral and symmetric and can form along the lines of minor trauma (Köbner phenomenon). Oral LP is often asymptomatic but can be associated with pain or irritation. The diagnosis of LP is based primarily on examination, but biopsy should be considered for confirmation, especially in patients with erythematous mucosal atrophy or ulceration. Treatment includes topical high-potency glucocorticoids (eg, fluocinonide). Unlike cutaneous LP, which is self-limited and often resolves within 2 years, oral LP often has a prolonged course with relapsing symptoms over many years. (Choice A) Aphthous stomatitis (canker sores) presents acutely with painful ulcers. Although recurrences are common, individual episodes usually last only a few days, and the mucosa returns to normal in the interim. Aphthous stomatitis (canker sores) (Choice B) Primary oral herpes simplex infection typically presents as gingivostomatitis in children or pharyngitis in adults, along with fever and lymphadenopathy. Recurrences present with clusters of ulcerating vesicles on the lips and perioral skin. (Choice D) Oral candidiasis (thrush) manifests as loosely adherent, fluffy, white exudates on the oral mucosa. It is most commonly seen in patients with underlying immune suppression. Wickham striae make LP more likely. Oral candidiasis (thrush) Educational objective: Oral lichen planus (LP) presents with white papules and plaques on the oral mucosa; variants may also show erythematous mucosal atrophy or ulceration. It is often associated with hepatitis C. Treatment includes topical high-potency glucocorticoids. Unlike cutaneous LP, which is self-limited, oral LP often has a prolonged course with relapses over many years. References: Oral lichen planus: An update on pathogenesis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/22529568)

A 46-Year-Old Man Comes to the Office Due to Discomfort