Esophageal Lichen Planus: Understanding a Potentially Severe Stricturing Disease

Abstract

A 67-year-old woman with a long-standing history of recurrent dysphagia and esophageal strictures failed to respond to aggressive antireflux management. She required multiple dilations for symptomatic strictures that were discovered throughout the esophagus. Intralesional, topical, and systemic glucocorticoid therapies were utilized without resolution in symptoms. Several years after initial presentation, histopathology ultimately demonstrated lichenoid features and a diagnosis of esophageal lichen planus (ELP) was confirmed. However, as her symptoms had already become significantly disabling with severe strictures that carried an increased risk of endoscopic complications with dilation, she ultimately decided to undergo an esophagectomy for definitive treatment. Moreover, ELP may often go unrecognized for several years. Clinicians should consider ELP in the differential for dysphagia in middle- to elderly-aged women with or without a known history of lichen planus (LP) especially for those with findings of multiple or proximal strictures.

No lesion? No problem: case of oesophageal lichen planus in a patient without any cutaneous lesions

“…Due to its rare nature, there is a paucity of data investigating ELP, and our understanding of the disease is mainly derived from case reports and case series. The most common presenting symptom is dysphagia, though some patients may also experience odynophagia and many are asymptomatic 3 5–8. A review of 72 cases of ELP performed by Fox et al showed that 99% of this cohort had extraoesophageal manifestations of lichen planus, most often oral (89%), vulvovaginal/anogential (42%) and cutaneous (38%) 5.…”

“…Data show that the majority of ELP involves the proximal third of the oesophagus 5. Histopathology is very important in making a diagnosis, and the presence of Civatte bodies, necrotic keratinocytes that appear eosinophilic on light microscopy, is confirmatory for ELP 3–8. Direct immunofluorescence can be used if histology is inconclusive 9.…”

Esophageal Lichen Planus Stricture

“…The disorder predominantly involves middle-aged to elderly women (approximately 87% of women with a median age of 61.9 years. 6 Dysphagia is the most common symptom followed by odynophagia and food impaction. 4,6 EGD plays a diagnostic and therapeutic role in these patients and should be performed in all patients with LP and GI symptoms.…”

“…6 Dysphagia is the most common symptom followed by odynophagia and food impaction. 4,6 EGD plays a diagnostic and therapeutic role in these patients and should be performed in all patients with LP and GI symptoms. Macroscopic findings are non-specific but include ulcers, erosions, stricture formation, whitish papules, esophageal pseudomembranes as well as inflamed and friable mucosa.…”

“…Macroscopic findings are non-specific but include ulcers, erosions, stricture formation, whitish papules, esophageal pseudomembranes as well as inflamed and friable mucosa. 1,4,6 The findings may be mistaken for reflux esophagitis, eosinophilic esophagitis, or candida esophagitis. 4 Most patients with LP were already on steroids and immunosuppressive medications, which make the diagnosis of candidiasis even more probable.…”