Peer Reviewed

Photo Essay

An Atlas of Lingual Lesions, Part 4

  • Alexander K. C. Leung, MD
    Clinical Professor of Pediatrics, University of Calgary; Pediatric Consultant, Alberta Children’s Hospital, Calgary, Alberta, Canada

    Benjamin Barankin, MD
    Dermatologist, Medical Director, and Founder, Toronto Dermatology Centre, Toronto, Ontario, Canada

    Kin Fon Leong, MD
    Pediatric Dermatologist, Pediatric Institute, Kuala Lumpur General Hospital, Kuala Lumpur, Malaysia

    Alex H. Wong, MD
    Clinical Assistant Professor of Family Medicine, University of Calgary, Calgary, Alberta, Canada

    Leung AKC, Barankin B, Leong KF, Wong AH. An atlas of lingual lesions, part 4. Consultant. 2019;59(8):242-245.

    EDITOR’S NOTE: This article is part 4 of a 5-part series of Photo Essays describing and differentiating conditions affecting the tongue and related structures in the oral cavity. Part 1 was published in the May 2019 issue, part 2 was published in the June 2019 issue, and part 3 was published in the July 2019 issue. Part 5 will be published in an upcoming issue of Consultant.


    Lichen Planus

    Lichen planus is an inflammatory dermatosis of unknown origin that typically affects the skin, mucous membranes, and nails. One or several areas can be involved, either concomitantly or sequentially.1

    Cutaneous lichen planus is the most common presentation characterized by 6 p’s: planar (flat-topped), purple (violaceous), polygonal, pruritic, and papules/plaques that affect the skin (Figure 1).1,2 The lesions of lichen planus are often superimposed by lacy, reticular, white lines known as Wickham striae, best seen in the buccal mucosa or after skin lesions are swiped with an alcohol wipe.1,2 Sites of predilection include the flexor aspects of the wrists and ankles, dorsa of hands, trunk, shins, and glans penis.3 The distribution is often symmetric. As with psoriasis, the Koebner phenomenon is particularly characteristic.2

    Fig 1
    Figure 1.

    There are 3 main forms of oral lichen planus: reticular, erosive/ulcerative, and atrophic.2,4 By far, the most common site is the buccal mucosa, followed by the tongue, gingiva, and vestibule.4 The reticular form is most common and typically presents as diffuse, bilateral, asymptomatic papules or plaques interlaced with Wickham striae on the oral mucosa.4,5 The erosive form presents as ulceration, erythema, and keratotic areas, as is illustrated in Figure 2. Patients with erosive lesions may report pain or a burning sensation in the mouth, exacerbated by eating acidic or spicy foods. The atrophic form presents as a red, diffuse lesion with mucosal atrophy. Other forms include plaque-like, hypertrophic, papular, and bullous.6 Sites of predilection are the buccal mucosa, tongue, and gingiva.7-9 Involvement of the palate, lips, and floor of the mouth is rare.9 The diagnosis is mainly a clinical one. A biopsy should be considered if the diagnosis is in doubt.

    Fig 2
    Figure 2.

    The prevalence of oral lichen planus has been estimated to be 0.2% to 2.2% of the population.8-10 The female to male ratio is 1.5 to 3:1.11 The typical age of onset is between 30 and 60 years of age.9

    Although the exact etiology is not known, an immune-mediated pathogenesis has been recognized.7 The overrepresentation of certain HLA haplotypes (eg, HLA-A3, HLA-A5, HLA-B8, HLA-Bw35, and HLA-DR1) suggests that genetic factors may be operative.12 There is an association between oral lichen planus and hepatitis C virus infection.13

    The erosive form of oral lichen planus can be quite painful and may interfere with speech, chewing, gustatory function, and swallowing and even result in weight loss.4,5,11,14 Whereas cutaneous lichen planus is self-limited, oral lichen planus tends to run a chronic, persistent course characterized by remissions and relapses.8-10 Complete remission is rare.7,10 A 2018 systematic review of 21 studies enrolling a total of 6559 patients showed that the malignant transformation rate to squamous cell carcinoma with oral-erosive lichen planus was 1.37%.15 Female gender, involvement of the tongue, and erosive type of the lesion increased the malignant transformation rate.15

    Because oral lichen planus is an immunologically related disease, medium- to high-potency topical corticosteroids are the treatment of choice.11,16 Other treatment options include topical calcineurin inhibitors, and systemic cyclosporine, mycophenolate mofetil, acitretin, or methotrexate.6,11,17 Oral corticosteroids may be considered in recalcitrant cases.11


    1. Leung AKC, Barankin B. Lichen planus. Consultant. 2014;54(2):137-138.
    2. Usatine RP, Tinitigan M. Diagnosis and treatment of lichen planus. Am Fam Physician. 2011;84(1):53-60.
    3. Lehman JS, Tollefson MM, Gibson LE. Lichen planus. Int J Dermatol. 2009;​48(7):682-694.
    4. Hargitai IA. Painful oral lesions. Dent Clin North Am. 2018;62(4):597-609.
    5. Au J, Patel D, Campbell JH. Oral lichen planus. Oral Maxillofacial Surg Clin North Am. 2013;25(1):93-100.
    6. Gupta A, Sardana K, Gautam RK. Looking beyond the cyclosporine “swish and spit” technique in a recalcitrant case of erosive lichen planus involving the tongue. Case Rep Dermatol. 2017;9(3):177-183.
    7. Barbosa NG, Silveira ÉJD, Lima ENA, Oliveira PT, Soares MSM, de Medeiros AMC. Factors associated with clinical characteristics and symptoms in a case series of oral lichen planus. Int J Dermatol. 2015;54(1):e1-e6.
    8. López-Jornet P, Camacho-Alonso F. Tongue involvement in patients with lichen planus. A retrospective study. J Eur Acad Dermatol Venereol. 2009;​23(2):204-205.
    9. Werneck JT, Costa TdO, Stibich CA, Leite CA, Dias EP, Silva Junior A. Oral lichen planus: study of 21 cases. An Bras Dermatol. 2015;90(3):321-326.
    10. Padmini C, Bai KY, Chaitanya V, Reddy MS. Ulcerative lichen planus in childhood. Case Rep Dent. 2013;2013:874895.
    11. Park H-K, Hurwitz S, Woo S-B. Oral lichen planus: REU scoring system correlates with pain. Oral Surg Oral Med Oral Pathol Oral Radiol. 2012;114(1):​75-82.
    12. Kanwar AJ, De D. Lichen planus in childhood: report of 100 cases. Clin Exp Dermatol. 2009;35(3):257-262.
    13. Lauritano D, Arrica M, Lucchese A, et al. Oral lichen planus clinical characteristics in Italian patients: a retrospective analysis. Head Face Med. 2016;​12:18.
    14. Suter VGA, Negoias S, Friedrich H, Landis BN, Caversaccio M-D, Bornstein MM. Gustatory function and taste perception in patients with oral lichen planus and tongue involvement. Clin Oral Investig. 2017;21(3):957-964.
    15. Richards D. Malignant transformation rates in oral lichen planus. Evid Based Dent. 2018;19(4):122.
    16. Chiang C-P, Chang JY-F, Wang Y-P, Wu Y-H, Lu S-Y, Sun A. Oral lichen planus—differential diagnoses, serum autoantibodies, hematinic deficiencies, and management. J Formos Med Assoc. 2018;117(9):756-765.
    17. Mirza S, Rehman N, Alrahlah A, Alamri WR, Vohra F. Efficacy of photodynamic therapy or low level laser therapy against steroid therapy in the treatment of erosive-atrophic oral lichen planus. Photodiagnosis Photodyn Ther. 2018;21:404-408.

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