Esophageal Lichen Planus as a Cause of Dysphagia: Literature Review and Clinical Observation

Aim: to analyze the literature data, and to raise awareness of doctors of various specialties about the methods of diagnosis and treatment of esophageal lichen planus (ELP).

Key points. In a 67-year-old female patient with complaints of difficulty swallowing solid food and weight loss, esophagogastroduodenoscopy revealed subcompensated stenosis of the middle third of the esophagus and signs of fibrinous esophagitis. Based on the characteristics of the endoscopic picture and the detection of apoptotic Ciwatt bodies in esophageal biopsies, a diagnosis of ELP was established. Treatment with glucocorticosteroids led to relief of symptoms and positive endoscopic dynamics. ELP is rare and the least studied, data on this disease in the 

literature are presented mainly in the form of clinical observations and analysis of series of cases. Typical clinical manifestations include dysphagia and odynophagia. Despite the low prevalence, ELP can be associated with serious complications: stenosis and esophageal squamous cell carcinoma. Endoscopic examination reveals characteristic signs in the esophagus: swelling, thickening and increased vulnerability of the mucosa, often with fibrin, formation of membranes and strictures. The histological picture is represented by epithelial dyskeratosis with exfoliation, lichenoid lymphocytic infiltration. The most specific histological sign is the presence of apoptotic Civatte bodies. Recommendations for the treatment of ELP are limited to the results of a series of clinical observations and include the prescription of systemic corticosteroids. The issue of supportive therapy is the least studied.

Conclusion. Analysis of the literature data and the clinical case demonstrate that lichen planus of the esophagus is one of the rare causes of dysphagia. Characteristic endoscopic and histological signs are key for the diagnosis. The management of patients with esophageal lichen planus is insufficiently defined and today includes taking of glucocorticosteroids, endoscopic dilation of stricture and dynamic endoscopic observation, given the high risk of squamous cell carcinoma in this category of patients.

1. Russian Society of Dermatovenereologists and Cosmetologists. Lichen planus: Clinical guidelines., 2020. (In Russ.).

2. Chandan V.S., Murray J.A., Abraham S.C. Esophageal lichen planus. Arch Pathol Lab Med. 2008;132(6):1026–9. DOI: 10.5858/2008-132-1026-ELP

3. Ismail S.B., Kumar S.K., Zain R.B. Oral lichen planus and lichenoid reactions: Etiopathogenesis, diagnosis, management and malignant transformation. J Oral Sci. 2007;49(2):89–106. DOI: 10.2334/josnusd.49.89

4. Katzka D.A., Smyrk T.C., Bruce A.J., Romero Y., Alexander J.A., Murray J.A. Variations in presentations of esophageal involvement in lichen planus. Clin Gastroenterol Hepatol. 2010;8(9):777–82. DOI: 10.1016/j.cgh.2010.04.024

5. de Mattos Camargo Grossmann S., de Aguiar M.C., Teixeira R., do Carmo M.A. Oral lichen planus and chronic hepatitis C: A controversial association. Am J Clin Pathol. 2007;127(5):800–4. DOI: 10.1309/HDWCT36P0GMGP40V

6. Wang Y., Hao Y., Tang F., Chen Q. Immune mechanisms involved in the coexistence of oral lichen planus and autoimmune thyroid diseases. Zhejiang Da Xue Xue Bao Yi Xue Ban. 2021;50(2):222–8. DOI: 10.3724/zdxbyxb-2021-0124

7. Druüijaniü A., Glavina A., Draganja M., Bioüina-Lukenda D., Cigiü L. Inflammatory markers and incidence of other autoimmune diseases in patients with oral lichen planus. Acta Stomatol Croat. 2019;53(4):363–70. DOI: 10.15644/asc53/4/7

8. Gubod E.R., Ramanathan A., Mohamad Zaini Z., Warnakulasuriya S. Oral lichen planus in a patient with a thymoma: A rare finding. Cureus. 2021;13(8):e17376. DOI: 10.7759/cureus.17376

9. Chung P.I., Hwang C.Y., Chen Y.J., Lin M.W., Chen T.J., Hua T.C. Autoimmune comorbid diseases associated with lichen planus: A nationwide case-control study. J Eur Acad Dermatol Venereol. 2015;29(8):1570–5. DOI: 10.1111/jdv.12939

10. Terziroli Beretta-Piccoli B., Invernizzi P., Gershwin M.E, Mainetti C. Skin manifestations associated with autoimmune liver diseases: A systematic review. Clin Rev Allergy Immunol. 2017;53(3):394–412. DOI: 10.1007/s12016-017-8649-9

11. Dvoriankova E.V. Anogenital forms of lichen planus. Klinicheskaya Dermatologiya i Venerologiya. 2019;18(6):762–7. (In Russ.). DOI: 10.17116/klinderma201918061762

12. Schauer F., Monasterio C., Technau-Hafsi K., Kern J.S., Lazaro A., Deibert P., et al. Esophageal lichen planus: Towards diagnosis of an underdiagnosed disease. Scand J Gastroenterol. 2019;54(10):1189–98. DOI: 10.1080/00365521.2019.1674375

13. Rao B., Gulati A., Jobe B., Thakkar S. Esophageal lichen planus: Understanding a potentially severe stricturing disease. Case Rep Gastrointest Med. 2017;2017:5480562. DOI: 10.1155/2017/5480562

14. Nielsen J.A., Law R.M., Fiman K.H., Roberts C.A. Esophageal lichen planus: A case report and review of the literature. World J Gastroenterol. 2013;19(14):2278–81. DOI: 10.3748/wjg.v19.i14.2278

15. Eisen D. The evaluation of cutaneous, genital, scalp, nail, esophageal, and ocular involvement in patients with oral lichen planus. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1999;88(4):431–6. DOI: 10.1016/s10792104(99)70057-0

16. Quispel R., van Boxel O.S., Schipper M.E., Sigurdsson V., Canninga-van Dijk M.R., Kerckhoffs A., et al. High prevalence of esophageal involvement in lichen planus: A study using magnification chromoendoscopy. Endoscopy. 2009;41(3):187–93. DOI: 10.1055/s-0028-1119590

17. Kern J.S., Technau-Hafsi K., Schwacha H., Janb K.M., Gunthere H., et al. Esophageal involvement is frequent in lichen planus: Study in 32 patients with suggestion of clinicopathologic diagnostic criteria and therapeutic implications. Eur J Gastroenterol Hepatol. 2016;28(12):1374–82. DOI: 10.1097/MEG.0000000000000732

18. Fox L.P., Lightdale C.J., Grossman M.E. Lichen planus of the esophagus: What dermatologists need to know. J Am Acad Dermatol. 2011;65(1):175–83. DOI: 10.1016/j.jaad.2010.03.029

19. Rauschecker A.M., Levine M.S.., Whitson M.J., Tondon R., Rubesin S.E., Furth E.E., et al. Esophageal lichen planus: Clinical and radiographic findings in eight patients. AJR Am J Roentgenol. 2017;208(1):101–6. DOI: 10.2214/AJR.16.16793

20. Plotnikova E.U., Vologzhanina L.G., Igumnova O.A., Kolmogorova T.O. Principles of management of chronic esophagitis of various etiologies. Medical Council. 2017;20:124–30. (In Russ.). DOI: 10.21518/2079-701X-2017-20-124-130

21. Ivashkin V.T., Maev I.V., Trukhmanov A.S., Rumyantseva D.E. Modern advances in the diagnosis and treatment of refractory gastroesophageal reflux disease. Terapevticheskii arhiv. 2018;90(8):4–12. (In Russ.). DOI: 10.26442/terarkh20189084-12

22. Teixeira C., Alves A.L., Cremers I. Esophageal lichen planus: A rare case. Rev Esp Enferm Dig. 2018;110(1):67–8. DOI: 10.17235/reed.2017.5332/2017

23. Pittman M.E., Hissong E., Katz P.O., Yantiss R.K. Lymphocyte-predominant esophagitis: A distinct and likely immune-mediated disorder encompassing lymphocytic and lichenoid esophagitis. Am J Surg Pathol. 2020;44(2):198–205. DOI: 10.1097/PAS.0000000000001394

24. Sato Y., Takenaka R., Matsumi A., Takei K., Okanoue S., Yasutomi E., et al. A Japanese case of esophageal lichen planus that was successfully treated with systemic corticosteroids. Intern Med. 2018;57(1):25–9. DOI: 10.2169/internalmedicine.8668-16

25. Rosic Despalatovic B., Bratanic A., Puljiz Z., Bozikovic J. Esophageal stenosis in a patient with lichen planus. Case Rep Gastroenterol. 2019;13(1):134–9. DOI: 10.1159/000498907

26. Franco D.L., Islam S.R., Lam-Himlin D.M., Fleischer D.E., Pasha S.F. Presentation, diagnosis, and management of esophageal lichen planus: A series of six cases. Case Rep Gastroenterol. 2015;9(2):253–60. DOI: 10.1159/000437292

27. Parvez M., Rai V., Khan E.M., Goenka M.K. Esophageal lichen planus: A rare and under-recognized disorder. J Dig Endosc. 2016;7(1):33–5. DOI: 10.4103/09765042.180099

28. Acar S., Koksal A.S., Tozlu M., Gonullu E., Eminler A.T. Treatment of esophageal stricture due to lichen planus with intralesional triamcinolone injection. Eur J Gastroenterol Hepatol. 2021;33(12):1611. DOI: 10.1097/MEG.0000000000002235

29. Arshad T., Fleckenstein K., Sardana N., Scudera P.L. No lesion? No problem: Case of oesophageal lichen planus in a patient without any cutaneous lesions. BMJ Case Rep. 2020;13(3):e232375. DOI: 10.1136/bcr-2019-232375

30. Kooybaran N.R., Petzold G., Ströbel P., Schön M.P., Mössner R. Alleviation of erosive oral and esophageal lichen planus by the JAK1 inhibitor upadacitinib. J Dtsch Dermatol Ges. 2021;19(12):1778–80. DOI: 10.1111/ddg.14612

31. Ravi K., Codipilly D.C., Sunjaya D., Fang H., Arora A.S., Katzka D.A. Esophageal lichen planus is associated with a significant increase in risk of squamous cell carcinoma. Clin Gastroenterol Hepatol. 2019;17(9):1902–3.e1. DOI: 10.1016/j.cgh.2018.10.018