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Oral Lichenoid Drug Eruption: A Report of aPediatric Case and Review of the Literature

Victoria Woo, D.D.S.,* Julia Bonks, D.M.D., Lyubov Borukhova, D.M.D.,

and David Zegarelli, D.D.S.

*School of Dental Medicine, University of Nevada, Las Vegas, Nevada, Columbia University College of Dental

Medicine, New York, New York

Abstract:Lichenoid drug eruptions are seen most frequently on the

skin and seldomly affect the mucosal surfaces. Oral involvementknown as

oral lichenoid drug eruptionis more common in the adult population and

has been associated with numerous medications. Pediatric-onset oral lich-

enoid drug eruption is an exceptionally rare finding with only isolated cases

published in the literature. The nonspecific appearance and latent presen-

tation of pediatric oral lichenoid drug eruption can cause confusion in

diagnosis and treatment. We report a case of oral lichenoid drug eruption

occurring in a 15-year-old and explore challenges in the clinical and histo-

logic recognition of this condition.

Drug eruptions represent a spectrum of cutaneous

and mucosal changes related to oral, parenteral, orinhaled exposure to medications (1,2). The clinical pre-

sentation of drug eruptions is variable and may mimic

the immune-mediated mucosal diseases including lichen

planus, pemphigus vulgaris, mucous membrane pem-

phigoid, and lupus erythematosus (LE) (3). A well-

recognized form of chronic drug reaction is the lichenoid

drug eruption (LDE), which may manifest on the skin,

oral mucosa, or both sites (4); of the two, oral LDE

(OLDE) is less common than cutaneous LDE (57) and

may occur independently of skin lesions (4). The intra-

oral sites of predilection of OLDE include the posterior

buccal mucosa, tongue, floor of mouth, palate, and

alveolar ridges (810). There appears to be a preferencefor unilateral distribution (1113). Clinically, lesions of

OLDE are morphologically identical to those of idio-

pathic oral lichen planus (OLP). They can exhibit a

classic reticular pattern or a predominantly erosive pat-

tern, depending on the drug implicated (14). Further-more, thehistologic appearance andimmunologic profile

of drug-induced lichenoid lesions are nearly identical to

their idiopathic counterpart (6,1517).

Oral lichenoid drug eruptions have been reported in

association with an extensive list of medications. The

most commonly implicated drug classes include: peni-

cillamine (5,18), antimalarials (19), gold salts (5,12),

antihypertensives, including b-blockers (4,5,18,20,21)

and angiotensin inhibitors (5,6,2123), nonsteroidal

antiinflammatory drugs (5,24,25), and HIV medications

(5,26,27). The time from initial medication intake to

lesion appearance is variable, ranging from weeks to

months with an average delay in onsetof 23 months (6).Demographically, OLDEs tend to be seen in adult

patients and are rare findings in the pediatric population

(7), which the authors consider to be patients 15 years of

Address correspondence to Victoria Woo, D.D.S., ColumbiaUniversityDivision of Oral Pathology, 630 W. 168th Street,PH15W-1562 New York, NY 10032, or e-mail: [email protected].

DOI: 10.1111/j.1525-1470.2009.00953.x

458 2009 The Authors. Journal compilation 2009 Wiley Periodicals, Inc.

Pediatric Dermatology Vol. 26 No. 4 458464, 2009


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age or younger. The disparity in prevalence is likely due

to the more frequent use of medications and to the

multiplicity of medications used in older individuals in

our older population. Moreover, the majority of medi-

cations associated with OLDE are used for the treatment

of predominantly adult-onset conditions (7).

In this article, we present a pediatric patient with

OLDE who demonstrated dramatic improvement on

discontinuation of his systemic medications.

CASE REPORT

A 15-year-old male was referred for evaluation of bilat-

eral buccal mucosal and tongue lesions of more than

1-yearduration.Thepatientreportedthathislesionswere

painful, particularly when exposed to certain foods and

liquids. A past medical history revealed that he was under

treatment by a psychiatrist for insomnia and mood

swings. His medications included risperidone (Risper-dal) and carbamazepine (Tegretol), which he had been

taking for2 years. Further questioningrevealed no other

medical conditions, no family history of lichen planus

(LP), no history of hepatitis B vaccination, and no sig-

nificant exposure to cinnamon-containing products or

foodstuffs. On intraoral examination, erosivelesionswith

white striatedperipheral borderswereobserved involving

the right and left buccal mucosa (Fig. 1A) and lateral

tongue borders (Fig. 1B). The ulcers corresponded to the

occlusal planes, suggestive of a Koebner phenomenon. A

predominantly reticular lesion was also evident upon the

lower labial mucosa. There were no adjacent dental res-torations and no cutaneous involvement was noted. The

clinical differentialdiagnosis includedOLP versus an oral

mucosal lichenoid reaction. A biopsy was performed of

the left buccal mucosa and revealed hyperparakeratosis

with an underlying lichenoid infiltrate containing scat-

tered neutrophils. Interface mucositis, characterized by

intraepitheliallymphocytic exocytosisandcolloidbodies,

was also evident (Fig. 2). A histopathologic diagnosis of

hyperkeratosis and lichenoid mucositis was made. The

patient was provided with a topical steroid mouthrinse

(dexamethasone suspension 0.5 mg5mL). On follow-up

2 weeks later the lesions were unchanged. An OLDE re-

lated to the patients medications was stronglysuspected.Upon consultation with the patients psychiatrist, both

medications were stopped. On follow-up 1 month later,

the patient reported 100% subjective improvement in his

symptoms. Clinically, there was almost complete resolu-

tion of the ulcerations although residual white striations

were noted involving the right and left posterior buccal

mucosa (Fig. 3A). The bilateral tongue borders were

clinically normal (Fig. 3B). A drug re-challenge was

offered but refused by his parents due to discomfort

A

B

Figure 1. (A) Oral lichenoid eruption: Erosions associated

with white striations of left buccal mucosa. (B) Oral lichenoideruption: Large erosion with white, striated periphery of leftlateral tongue border.

Figure 2. Photomicrograph of oral biopsy demonstrating alichenoid infiltrate with intraepithelial lymphocytes and colloidbodies (hematoxylin and eosin, magnification 100).

Woo et al: Oral Lichenoid Drug Eruption 459


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associated with his initial lesions. At 1-year follow-up,

there were persistent reticular lesions of the bilateral

buccal mucosa butno evidence of ulceration. The patient

has been placed on annual oral pathology recall and

continues to be followed closely by his psychiatrist.

DISCUSSION

Pediatric LDE is infrequent due to the relative uncom-

mon use of systemic medications in this age group. A

review of the current literature revealed several cases of

cutaneous LDE in children (28,29). However, reports of

OLDE are extremely rare and may be related to lack ofrecognition or misdiagnosis as other clinical entities,

including idiopathic LP. We performed a Medline and

PubMed search for pediatric OLDE cases published in

the English-language literature andfound onlytwo cases,

presented in Table 1 (29,30). The patients listed in this

table fulfilled the criteria for OLDE, including a history

of systemic medication intake, clinical and histologic

evidence of lichenoid mucositis, and resolution of lesions

with drug cessation. It is noteworthy that formal analysis

of documented cases was often difficult due to a wide

variation in reporting techniques and diagnostic criteria.

A complete listing of OLDE-causing medicationsused in the pediatric population is beyond the scope of

this paper. However, an abbreviated list is provided in

A

B

Figure 3. (A) Appearance of oral mucosa 1 month following

drug withdrawal: Residual white striations of left buccalmucosa. (B) Appearance of oral mucosa 1 month followingdrug withdrawal: Left lateral tongue border with no clinicalevidence of disease.

TABLE 1. Reported Cases of Pediatric Oral Lichenoid Drug Eruption

AuthorNo.cases Agesex Drug implicated Site

Clinicalfeatures

Time onset*time resolve Comments

Ridola et al (29) 1 20 mosM Dactinomycin Lips, face trunk, limbs Reticular,papular

12 d1 mo Topical steroids given;resolution despitecontinued vincristine

Kanwar et al (30) 1 4 yrsM Dactinomycin Oral NS, axillae, groinpubic region, chest

NS 7 d1 mo

Present case 1 15 yrsM Risperidone,carbamazepine

BM, tongue Erosive ?mo1 mo

*Time of lesional onset after drug administration, Time of lesional resolution after drug withdrawal.M, male; NS, not specified; BM, buccal mucosa.

TABLE 2. OLDE-Associated Systemic Medications Used inthe Pediatric Population

Antianxietypsychotropic agents (clonazepam, diazepam,lorazepam, temazepam, tricyclic antidepressants)

Antibiotics (tetracycline)Anticonvulsants (carbamazepine, lorazepam, oxcarbazepine,

phenytoin, valproate sodium)Antidiabetics (insulin)Antidiarrheals (bismuth)

Antinflammatory agents (aspirin, fenclofenac, ibuprofen,naproxen, rofecoxib)

Antifungals (amphotericin B, ketoconazole)Antimalarials (chloroquine, hydroxychloroquine, pyrimethamine,quinidine, quinine)Antituberculosisantimycobacterial agents (isoniazid,

streptomycin, rifampin)Antiulcer agents (cimetidine, ranitidine, omeprazole)Bipolar agents (lithium)Chemotherapeutic agents (dactinomycin)Thyroid replacement agents (thyroxine)

OLDE, oral lichenoid drug eruption.

460 Pediatric Dermatology Vol. 26 No. 4 JulyAugust 2009


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Table 2 (8,3134). Of note, several of these medications

have been implicated in both oral and cutaneous

lichenoid eruptions.

The diagnosis of OLDE may be challenging due to its

nonspecific clinical findings and rarity in the pediatric

population. A clear temporal relationshipbetween lesion

onset and drug intake is not always obvious due to

variable latent periods, which ranges from an average of

12 months (29) to reportedly 2 years in duration

(6,24,35,36). Therefore, extended latency from initial

drug exposure does not preclude thediagnosis of OLDE.

Furthermore, oral lesions have presented after medica-

tion withdrawal in exceptional cases (37). In this setting,

a high index of clinical suspicion is required to prompt

evaluation of a drug-inducedetiology. Lastly, identifying

the causal agent can also become problematic in patients

taking multiple medications, although the most recently

administered drug should be suspected first.

Further complicating the diagnosis of OLDE is thewide array of oral conditions that can present with lich-

enoid-appearing lesions. The differential diagnosis for

OLDE in a child should include OLP, lichenoid amal-

gam reaction, and cinnamon stomatitis; less likely con-

siderations include lesions of LE, oral manifestations of

chronic graft-versus-host disease, and erythema multi-

forme. The latter five conditions can be excluded by

evaluating the following: direct contact with amalgam

restorations,exposure to cinnamon containing products;

systemic involvement and positive serologic tests for LE;

history of bone marrow transplant; and characteristic

clinical findings such as hemorrhagic crusted lips andtarget skin lesions (Table 3) (8,12). Hepatitis B vaccina-

tion (3840) and liver disorders, such as chronic active

hepatitis (41), have also been associated with oral

lichenoid lesions but can be appropriately eliminated

during history taking. Therefore, the main diagnostic

dilemma involves differentiating OLDE from OLP, the

latter being a rare but documented condition in children

(4246). Clinical, microscopic, and immunologic simi-

larities make distinction between OLDE and OLP diffi-

cult if not impossible in certain cases. This is

compounded by the lack of clearly defined and stan-

dardized criteria in the diagnosis of OLDE. Attempts at

identifying histologic features specific to OLDE have

been met with variable success. Purported histologic

features favoring the diagnosis of OLDE include a deep

and diffuse subepithelial infiltrate composed of

lymphocytes, plasma cells, neutrophils with or without

eosinophils; perivascular inflammation; and intraepi-

thelial colloid bodies (4,12,13,15,4749). However, most

authors agree that these findings are not exclusive to

OLDE and can also be seen in OLP as well as other

mucocutaneous conditions (e.g., discoid LE) (15,47,50).

In contrast to traditional histology, immunofluorescenceanalysis may be of help in distinguishing OLDE from

OLP. While both conditions show similar findings on

direct immunofluorescence studiesnamely, a shaggy

deposition of fibrinogen along the basement membrane

zone and immunoglobulin M-positive colloid bodies

(5,8,51)detection of circulating basal cell cytoplasmic

autoantibodies (BCCA) by indirect immunofluorescence

may favor a diagnosis of OLDE (11). A positive BCCA

test, characterized by a distinct string of pearls pattern

on serum analysis, has been documented in OLDE by

many authors (11,52,53) and may be a useful ancillary

test to support a drug-induced etiology. Furthermore,immunofluorescence testing also serves to rule out

other immune-mediated vesiculobullous diseases, such

as LE, pemphigus vulgaris, and mucous membrane

pemphigoid.

TABLE 3. Differential Diagnosis of OLDE

Condition Agesex Sites Oral lesions Diagnosis

Oral lichen planus Middle-aged;elderlyF

Skin: flexor surfacesOral: BM, tongue, gingival

Bilateral, symmetric;reticular > erosive;exacerbations

Clinical; histology; DIF

Lichenoid amalgam

reaction

AnyM = F BM, lateralventral tongue;

contact with amalgam

White or atrophic

striations; persistent

Clinical; histology; ?mercury

patch testSystemic lupuserythematosus

Avg. 30 yrsF Multisystem: skin, kidney,cardiac

Oral: BM, palate, gingiva

Reticular; atrophic;nonspecific erosions

Clinical; histology; DIF;serology for ANA, dsDNA

Graft-versus-hostdisease

AnyM = F Multisystem: skin, GI, liverOral: BM, tongue, Lips

Reticular; papular;atrophic nonspecificerosions

History of bone marrowtransplant; clinical; histology

Erythema multiforme 2030 yrsM = F Skin: hands, feet, genitalOcular: conjunctivaOral: Lips, BM, tongue, FOM,

soft palate

Hemorrhagic crustingof lips; nonspecificulcers; rapid onset

Clinical; histology to rule outother ulcerative processes

F, female; M, male; BM, buccal mucosa; FOM, floor of mouth; DIF, direct immunofluorescence; ANA, antinuclear antibodies; dsDNA,double-stranded DNA antibodies; OLDE, oral lichenoid drug eruption.



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Although thereare no universally acceptedcriteria for

the diagnosis of OLDE, recent efforts by McCartan et al

(17) have provided a more structured system for

reporting cases. These authors suggest that reports

should include: (1) an accurate clinical description of

lesions with a defined temporal relationship with drug

exposure, (2) evidence of histologic verification, and (3)

documented lesion resolution on drug withdrawal.

Moreover, lesion recurrence on drug re-challenge

(provocation testing) and supportive immunofluores-

cence testing will also help to confirm a medication-re-

lated cause (5,54). Lastly, some authors have used patch

testing as an auxiliary tool in diagnosis (55), while others

contend that a negative patchtest cannot reliablyrule out

OLDE (56).

The ideal treatment for OLDE consists of drug

withdrawal or substitution with an alternate medication

following consultation with the patients physician (18).

Lesion resolution is typically observed within weeks tomonths after drug cessation although delayed responses

may result in lesion persistence (57). Furthermore, faint

residual striations or milder forms of erosive lesions

are commonly observed following elimination of the

medication (12), as seen in our patient.In many instances

however, the severity of the medical condition for which

the patient is being treated precludes drug discontinua-

tion. In such cases, topical steroid therapy has been used

but with variable to little success (24). Reportedly, select

adult patients have benefited from systemic corticoste-

roid therapy (18), topical tacrolimus (58), and topical

acetretin (59), although such treatments should be usedwith appropriate caution in children. Palliative remedies

such as temporary mucosal protectants (e.g., milk of

magnesia) may provide symptomatic relief (18). In

addition, good oral hygiene practices are to be encour-

aged to prevent superimposed bacterial and fungal

infections (18).

In this report, the patient was taking risperidone and

carbamazepine as prescribed by his psychiatrist. Ris-

peridone is an antipsychotic agent used to manage

schizophrenia and bipolar disorder. This medication is

most often associated with central nervous system side

effects such as agitation, somnolence, and dizziness (60).

Carbamazepine is an anticonvulsant primarily indicatedfor treatment of epilepsy with similar neurologic side-

effects as risperidone. To our knowledge, risperidone has

been associated with lichenoid dermatitis (60) but is nota

documented cause of OLDE. In contrast, carbamaze-

pine has been implicated in OLDEs (8,11,31,61), cuta-

neous LDEs (61,62), lupus erythematosus-like drug

eruptions (8,63,64) and fixed drug eruptions (8,65).

Although it cannot be stated with certainty which agent

caused the OLDE in our patient, carbamazepine is

favored due to its more extensive history of drug

reactions.

In summary, the presentation of lichenoid lesions in

the pediatric population should prompt evaluation for

OLP and other conditions with intraoral lichenoid

manifestations. A thorough history of systemic drug in-

take over the previous 12 months should be documented

as a means to eliminate or support a diagnosis of OLDE

(5). Dueto the increasing recognitionandpharmacologic

management of childhood-onset illnesses, including

attention deficithyperactivity disorder (66), it is possible

that drug-related side-effects and oral complications may

become more prevalent in the younger population.

Therefore, it is important for clinicians to recognize the

spectrum of medication-induced conditions, including

OLDE, in order to avoid delays in diagnosis and

treatment.

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