HPI: The patient is an otherwise healthy and alert 92 year old woman with painful erosions of tongue and vulva for six years. She has marked pain with eating and urination. Mouth lesions preceded genital lesions by a few years. She has been followed for erosive lichen planus but it is unclear if any biopsies were positive. She has lost weight because her painful tongue causes her to avoid eating. She has been treated with clobetasol ointment, Viscous Lidocaine was not effective.
O/E: Erosive lesions of tongue and labia. No bullae noted. Remainder of cutaneous exam unremarkable.
Clinical Photos:
Pathology: Biopsy of genital labial skin shows papillary dermal fiborsis and a mild superficial perivascular mixed inflammatory cell infiltrate. No lichenoid infiltrate. Direct immunofluorescence from perilesional skin was negative. PASD negative for fungi.
Diagnosis: Painful erosions mouth and genitalia. At present no support for lichen planus or bullous process histologically.
Questions: What are your thoughts? Her oral pain makes eating difficult and negatively affects her quality of life. Are there other therapies that we could consider?
You could try cyclosporin solution (swish and spit)
ReplyDeleteSteve Higgins
Erosive lichen planus is likely diagnosis. Usual histopathology is 'nonspecific inflammation' in the vulva. I would continue daily clobetasol ointment, intravaginal hydrocortisone foam and consider prednisone at 40 mg for a couple of weeks then reducing over 12 weeks while also commencing methotrexate. Methotrexate is slow to work but can make a big difference to symptoms. In a very old person, methotrexate may be toxic so check renal function and start low dose and slowly increase while checking CBC and LFT.
ReplyDeleteI'd put nutritional deficiency high up on the DDx. Especially in elderly patients who often have a "tea and toast" diet, vitamin deficiency is a common cause of glossitis and erosions in the genital area. I would check serum levels of niacin (vit B3), pyridoxine (vit B6) folate, and vitamin B12 at a minimum. Could also consider checking zinc levels although would expect more periorificial eczematous dermatitis in this scenario.
ReplyDeleteAlthough I see no aphthae, aphthosis/Behcet's is a possibility, especially if multiple biopsies have not shown LP. How about colchicine?
ReplyDeleteSmacks of Behcet's Disease.
ReplyDeleteCould it be a drug reaction?
ReplyDelete