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Desquamtive Lesions- II

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2 Desquamtive Lesions- II
Vesiculobullous and Desquamtive Lesions- II Course 341 MDS Dr Asma’a Faden

3 Definitions: Normal mucosa. Vesicle. Bullae. Desquamative.

4 Bullae: A bulla is a blister more than 5 mm in diameter with thin walls that is full of fluid. In Latin a bulla was a "bubble, stud or knob." It referred to any rounded protrusion, particularly one that was hollow or cystic.

5 Desquamation: The shedding of the outer layers of the skin, for example, once the rash of measels fades, there is desquamation. The word comes from the Latin "desquamare" meaning "to scrape the scales off a fish."

6 (III) Bullous Diseases:
1- Pemphigus Vulgaris. 2- Bullous Pemphigoid. 3- Benign Mucous Membrane Pemphigoid. 4- Bullous Lichen Planus. 5- Erythema Multiforme. 6- Stevens-Johnson Syndrome. 7- Epidermolysis Bullosa. 8- Dermatitis Herpetiformis.

7 (IV) Desquamative Lesions:
1- Desquamative Gingivitis (Ginigivosis). 2- Erosive Lichen Planus. 3- Toothpaste Idiosyncrasy Lesions.

8 1- Filaments. 2- Desmosome. 3- Hemidesmosome. 4- Basal cell layer

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10

11 Bullous Diseases: Nikolsky’s sign:
A positive Nikolsky's sign signifies a separation of epithelial cells either from one another or from the basement membrane, which is a layer of connective tissue to which epithelium usually adhered. In these diseases, there are defects in the cell-to-cell attachement mechanisms, and even minute amounts of trauma can elicit a clinical response of a blister formation when the cells are manually detached with the forceful turn of the pencil eraser on the skin. In the case of pemphigus, the pencil twist easily rips the spinous cells apart because they possess defective desmosomes, and in the case of pemphigoid, the hemidesmosomes are defective. Within minutes, a blister will form, and this is pathognomonic, or absolutely indicative, of a vesicular/bullous disease

12 Bullous Diseases Caused by autoantibody-mediated disruption of adhesion between basal keratocytes and the basement membrane, i.e., antibodies there bind the antigens of Bullous Pemphigoid (BP). 

13 Pemphigoid: Pemphigoid is the term given to a group of sub-epithelial immunologically mediated vesiculobullous disorders which can affect stratified squamous epithelium. It is characterized by damage to one of the protein constituents of the basement membrane zone anchoring filament components. This group include “Mucous Membrane Pemphigoid”.

14 Pemphigus Pemphigus is a group of potentially life-threatening chronic autoimmune diseases characterized by blistering of the skin and mucous membranes diagnosed histologically by intradermal blister and immunopathologically by the finding of in-vivo bound and circulating immunoglobulin G (IgG) antibody directed against the cell surface of keratinocytes. Pemphigus Vulgaris is the most common Pemphigus variant, and the form usually responsible for oral lesions.

15 (III) Bullous Diseases:
1- Pemphigus Vulgaris. 2- Bullous Pemphigoid. 3- Benign Mucous Membrane Pemphigoid. 4- Bullous Lichen Planus. 5- Erythema Multiforme. 6- Stevens-Johnson Syndrome. 7- Epidermolysis Bullosa. 8- Dermatitis Herpetiformis.

16 - PV accounts for approximately 70% of Pemphigus cases.
Bullous Diseases: 1- Pemphigus Vulgaris - Pemphigus Vulgaris is potentially lethal disease. - It is a rare autoimmune mucocutaneous disorder, characterized by blistering of the skin and mucous membrane. - PV accounts for approximately 70% of Pemphigus cases. - The mouth is frequently the first site of attack. Age: middle-age and elderly Sex: Females predominantly Geographic: Ashkenazi Jewish, Asians or Mediterranean descent

17 Bullous Diseases: 1- Pemphigus Vulgaris Clinical Features:
- The oral changes are highly variable ranges from small blisters or erosions to widespread destruction of the oral epithelium Painful oral lesion may precede the development of skin lesion in 50% of the affected population. Rupture occurs within days leaving a broad areas of desquamation associated with erythema. - +ve Nikolsky’s sign.

18 Pemphigud Vulgaris: an ulcer with an intact basal cell area.
Bullous Diseases: 1- Pemphigus Vulgaris Pemphigud Vulgaris: an ulcer with an intact basal cell area.

19 Bullous Diseases: 1- Pemphigus Vulgaris Pemphigus Vulgaris: immunofluorescence staining with anti-IgG shows deposit along the intercellular borders of the epithelium and coating acantholytic cells.

20 Bullous Diseases: Clinical Features: 1- Pemphigus Vulgaris
- The skin changes may not develop for months after oral lesions have appeared or, at other extreme, dermal or ocular involvement may appear within days.

21 Bullous Diseases: 1- Pemphigus Vulgaris - Management:
Differential Diagnosis: Include: Pemphigoid, Erythema Multiforme, Pyostomatitis Vegetans and IgA Pemphigus. Careful history, biopsy, clinical and laboratory results (serum) is confirmative. - Management: Corticosteroids (topical and systemic)

22 (III) Bullous Diseases:
1- Pemphigus Vulgaris. 2- Bullous Pemphigoid. 3- Benign Mucous Membrane Pemphigoid. 4- Bullous Lichen Planus. 5- Erythema Multiforme. 6- Stevens-Johnson Syndrome. 7- Epidermolysis Bullosa. 8- Dermatitis Herpetiformis.

23 2- Bullous Pemphigoid Bullous Diseases:
Bullous Pemphigoid is a chronic mucocutaneous Bullous disease that usually affects older individuals - Autoimmunity. Bullous Pemphigoid antigens (BP180, BP230)are the main target antigens. Age: Mean age of 65 years at onset Sex: The disease affects women slightly more often than men (ratio 1.7 : 1)

24 2- Bullous Pemphigoid Bullous Diseases:
Clinical Features: The oral mucosa is affected in about 20–40% of cases, usually after skin involvement. The oral lesions usually follow cutaneous manifestations and begin as bullae that soon rupture, leaving shallow ulcerations. - Other mucous membranes may also be affected.

25 2- Bullous Pemphigoid Bullous Diseases:
Clinical Features: - Skin lesions are always present, and begin as a nonspecific generalized rash followed by large, tense bullae that rupture, leaving denuded areas without a tendency to extend peripherally. - The trunk, arms, and legs are the sites of predilection.

26 2- Bullous Pemphigoid Bullous Diseases:
Histopathological Descriptions: - Histopathological examination, direct and indirect immunofluorescence. Differential Diagnosis: - Pemphigus, Cicatricial Pemphigoid, linear IgA disease, Dermatitis Herpetiformis, Epidermolysis Bullosa Acquisita, Pemphigoid Gestationis. Management: Systemic steroids, immunosuppressive drugs. The prognosis is usually good.

27 (III) Bullous Diseases:
1- Pemphigus Vulgaris. 2- Bullous Pemphigoid. 3- Benign Mucous Membrane Pemphigoid. 4- Bullous Lichen Planus. 5- Erythema Multiforme. 6- Stevens-Johnson Syndrome. 7- Epidermolysis Bullosa. 8- Dermatitis Herpetiformis.

28 3- Benign Mucous Membrane Pemphigoid
Bullous Diseases: 3- Benign Mucous Membrane Pemphigoid - Is a chronic autoimmune disease of mucous membrane and/or skin. Age: - predominantly a disease of the elderly with a peak incidence at around 70 years. However, childhood cases have been reported. Sex: - It appears to be twice as common in women than men.

29 3- Benign Mucous Membrane Pemphigoid
Bullous Diseases: 3- Benign Mucous Membrane Pemphigoid Clinical Features: Mouth - Blisters form first on the gums near the teeth, Palate, tongue, lips, buccal mucosa, floor of the mouth and throat may be affected, Painful and make it difficult to eat. - Lesions occurring in the throat (oesophagus, trachea and larynx) can become life-threatening.

30 3- Benign Mucous Membrane Pemphigoid
Bullous Diseases: 3- Benign Mucous Membrane Pemphigoid

31 3- Benign Mucous Membrane Pemphigoid
Bullous Diseases: 3- Benign Mucous Membrane Pemphigoid Clinical Features: Skin - Blisters on the skin develop in 25-30% of patients. May be itchy - Bleeding may occur if traumatized.

32 Mucous Membrane Pemphigoid: The full thickness of epithelium has separated from the corium, which is edematous and infiltrated by inflammatory cells.

33 Mucous Membrane Pemphigoid: immunofluorescence shows deposition of C3 along the basement membrane zone.

34 3- Benign Mucous Membrane Pemphigoid
Bullous Diseases: 3- Benign Mucous Membrane Pemphigoid Differential Diagnosis: - Oral lesions may be confused clinically with Pemphigus, dermatitis herpetiformis and linear IgA disease or occasionally with erosive lichen planus, acquired epidermolysis bullosa, toxic epidermal necrolysis or erythema multiforme. Management: Topical steroids and referral to a specialist (including ophthalmologist) Sever cases needs heavy administration of steroids.

35 (III) Bullous Diseases:
1- Pemphigus Vulgaris. 2- Bullous Pemphigoid. 3- Benign Mucous Membrane Pemphigoid. 4- Bullous Lichen Planus. 5- Erythema Multiforme. 6- Stevens-Johnson Syndrome. 7- Epidermolysis Bullosa. 8- Dermatitis Herpetiformis.

36 Bullous Diseases: Clinical Features: 4-Bullous lichen Planus
- Bullous lichen planus is a rare form of lichen planus Clinical Features: It is clinically characterized by the formation of bullae that soon rupture, leaving painful shallow ulcerations. The bullae usually arise on a background of papules or striae with the typical pattern of lichen planus.

37 4-Bullous lichen Planus
Bullous Diseases: 4-Bullous lichen Planus Histopathological Descriptions: - Histopathological examination, direct immunofluorescence Differential Diagnosis: - Cicatricial Pemphigoid, linear IgA disease, Pemphigus, erythema multiforme, drug reactions Management: - Topical or systemic steroids in low doses, in severe cases.

38 (III) Bullous Diseases:
1- Pemphigus Vulgaris. 2- Bullous Pemphigoid. 3- Benign Mucous Membrane Pemphigoid. 4- Bullous Lichen Planus. 5- Erythema Multiforme. 6- Stevens-Johnson Syndrome. 7- Epidermolysis Bullosa. 8- Dermatitis Herpetiformis.

39 5- Erythema Multiforme Bullous Diseases:
- Erythema multiforme is an acute or subacute self-limiting disease that involves the skin and mucous membranes. - The etiology is unclear. However, an immunologically mediated process triggered by herpes simplex or Mycoplasma pneumoniae, drugs, radiation, or malignancies, is probable. Age: the ages of 20 and 30 years Sex: The disease more frequently affects young men.

40 5- Erythema Multiforme Bullous Diseases:
-The oral lesions present as coalescing small vesicles that rupture within two or three days, leaving irregular, painful erosions covered by a necrotic pseudomembrane. -The lips, buccal mucosa, tongue, soft palate, and floor of the mouth are most commonly involved.

41 5- Erythema Multiforme Bullous Diseases: Clinical Features:
The skin manifestations consist of erythematous, flat, round macules, papules, or plaques, usually in a symmetrical pattern. -The characteristic skin patterns are target- or iris-like lesions. Skin bullae may occasionally be seen. Conjunctivitis, balanitis, vulvitis, and prodromal symptoms such as headache, malaise, arthralgias, and fever, may also be present. Recurrences are common.

42 5- Erythema Multiforme Bullous Diseases:
Histopathological Descriptions: - Junctional separation, intraepithelail separation. Differential Diagnosis: - bullous lichen planus, pemphigus vulgaris, pemphigoid. Management: - Systemic steroids. Aciclovir may be helpful in cases of recurrence.

43 (III) Bullous Diseases:
1- Pemphigus Vulgaris. 2- Bullous Pemphigoid. 3- Benign Mucous Membrane Pemphigoid. 4- Bullous Lichen Planus. 5- Erythema Multiforme. 6- Stevens-Johnson Syndrome. 7- Epidermolysis Bullosa. 8- Dermatitis Herpetiformis.

44 6- Stevens-Johnson Syndrome
Bullous Diseases: 6- Stevens-Johnson Syndrome Stevens–Johnson syndrome, or erythema multiforme major, is a severe form of erythema multiforme that predominantly affects the mucous membranes, in which bullous and erosive erythematous lesions are found in the oral cavity. Drugs usually trigger the disease Age: young adults Sex: Male predilection

45 6- Stevens-Johnson Syndrome
Bullous Diseases: 6- Stevens-Johnson Syndrome Clinical Features: -The oral lesions are always present, and are characterized by extensive vesicle formation, followed by painful erosions covered by grayish-white or hemorrhagic pseudomembranes. - Typical iris are present.

46 6- Stevens-Johnson Syndrome
Bullous Diseases: 6- Stevens-Johnson Syndrome Clinical Features: - The lesions may extend to the pharynx, larynx, and esophagus. - The ocular lesions consist of conjunctivitis or uveitis. - The genital lesions are balanitis or vulvovaginitis, and scrotal erosions. - The skin manifestations may vary from very light to severe. - The diagnosis is mainly made on the basis of the clinical presentation.

47 6- Stevens-Johnson Syndrome
Bullous Diseases: 6- Stevens-Johnson Syndrome Differential Diagnosis: - Behçet disease, pemphigus, pemphigoid, primary herpes simplex. Management: - Systemic steroids; antibiotics, if considered necessary in severe cases.

48 (III) Bullous Diseases:
1- Pemphigus Vulgaris. 2- Bullous Pemphigoid. 3- Benign Mucous Membrane Pemphigoid. 4- Bullous Lichen Planus. 5- Erythema Multiforme. 6- Stevens-Johnson Syndrome. 7- Epidermolysis Bullosa. 8- Dermatitis Herpetiformis.

49 7- Epidermolysis Bullosa
Bullous Diseases: 7- Epidermolysis Bullosa Epidermolysis bullosa is a heterogeneous group of usually inherited mucocutaneous bullous disorders. Depending on the defective mechanism of cellular cohesion, three main inherited groups are recognized: simplex, junctional, and dystrophic. Each group includes several forms, depending on the inheritance pattern. Age: The lesions appear at birth or early in infancy Clinical Features: The clinical spectrum and the degree of severity may range from mild to severe or fatal.

50 7- Epidermolysis Bullosa
Bullous Diseases: 7- Epidermolysis Bullosa Clinical Features: Oral manifestations are more common in the junctional and dystrophic forms. Oral lesions present as bullae, usually in areas of friction, which rupture, leaving shallow ulcers, and later atrophy and scarring. Dysplastic teeth may be seen in the severe forms of the disease. Leukoplakia and quamous-cell carcinoma may develop on the scars.

51 7- Epidermolysis Bullosa
Bullous Diseases: 7- Epidermolysis Bullosa Clinical Features: - Skin lesions are characterized by the formation of bullae, followed by ulcerations and scarring, particularly in areas exposed to low-grade chronic trauma. - Nail involvement, deformities of hands and feet, and involvement of the larynx, pharynx, and esophagus are common in the recessive dystrophic type.

52 Histopathological Descriptions:
Desquamative Lesions 7- Epidermolysis Bullosa Histopathological Descriptions: - Histopathological examination, direct immunofluorescence. Differential Diagnosis: - Pemphigus, cicatricial and bullous pemphigoid, linear IgA disease, bullous dermatoses of childhood, epidermolysis bullosa acquisita. Management: - Supportive. Systemic steroids in severe cases

53 «الجفاء» قادهم لتعلم لغات أجنبية. و «الصحة» تشيّد مركزاً خاصاً بهم
«الجفاء» قادهم لتعلم لغات أجنبية... و «الصحة» تشيّد مركزاً خاصاً بهم ... حائل: 7 أطفال «محرومون» من حنان المجتمع بسبب «جلودهم»! حائل - سالم الثنيان     الحياة     - 07/12/07// يعيش سبعة أطفال تتراوح أعمارهم بين الثانية عشرة والخامسة عشرة في مركز خاص في مدينة حائل معزولين عن العالم الخارجي، لأنهم مصابون بمرض نادر يدعى «الجلد الفقاعي» يحرمهم من العيش بشكل طبيعي. تغطي الضمادات أجسادهم النحيلة لتحمي جلودهم الهشة من أي احتكاك قد يصيبهم ببثور وفقاعات مؤلمة، وعلى رغم ذلك يضحكون ويمارسون حياتهم بشكل يوضح أنهم راضون بقسمة الله. أقاموا أكثر من عقد في مركز أعدته لهم مديرية الشؤون الصحية في منطقة حائل، ومع تقدمهم بالسن قرر المسؤولون عزل الذكور عن الإناث، فأنشئ مركز للأطفال المصابين في مستشفى حائل العام، وبقيت الإناث في المركز التابع لمستشفى النساء والولادة. يبدو الأطفال ثريا وإيمان ووعد وعبير ورائد وعتيق وإبراهيم الذين زارتهم «الحياة» واعين بحقيقة مرضهم متقبلين له، على رغم «الغصة» التي يحسون بها، لأنهم نشأوا وترعرعوا على يد العاملين والعاملات في المستشفى، في ظل تخوف أسرهم من التعامل معهم لخطورة مرضهم وحساسية أجسادهم. ويتضح أثر ابتعاد الأطفال عن أسرهم ومجتمعهم عند التحدث معهم، فهم يجيدون التحدث بالإنكليزية والفيليبينية، وتأثروا ببعض العادات والتقاليد الأجنبية، نظراً إلى اختلاطهم منذ ولادتهم مع القائمين على علاجهم ورعايتهم. ويوجد معلّم متفرغ لتعليم الأطفال الذكور، ومعلمة لتعليم الإناث في المركز. ويفاجأ الزائر بأحلام هؤلاء الأطفال، فهي بسيطة بساطة نفوسهم المليئة بالحب، ومنها أن تبادر الجهات الحكومية كإدارة التعليم بتنظيم زيارات لهم بشكل منتظم لرفع معنوياتهم، ومشاركتهم الأعياد والمناسبات. يذكر أن «الجلد الفقاعي» - بحسب المصادر الطبية - مرض نادر يجعل الجلد هشاً جداً، ويؤدي إلى حدوث فقاقيع مائية متكررة ومؤلمة، تؤدي إلى حدوث جروح وقروح، وفي بعض أشكال المرض، تحدث ندبات على الجلد نتيجة تكرر تقرح الجلد والتئام الجرح. ومعظم أمراض الجلد الفقاعي وراثية، ولا تنحصر الإصابة في الجلد فقط، فربما تظهر البثور في الفم أو البلعوم أو المريء أو المعدة أو الأمعاء، وقد تتكون نتيجة أي احتكاك بسيط ببشرة المريض. ويعطى المصابون بالمرض مراهم وضمادات معينة، لتقليل الإحساس بالألم والمحافظة على الجروح خشية تلوثها، ما قد يؤدي إلى إصابتهم بأمراض أخرى. من جهته، ذكر مدير مستشفى حائل العام الدكتور عبدالعزيز النخيلان لـ «الحياة»، أن وزارة الصحة بدأت إنشاء أول مركز لعلاج المصابين بانحلال الجلد الفقاعي بكلفة 20 مليون ريال شرق مبنى المستودعات الطبية في مدينة حائل، مضيفاً أن المركز يقدم للمصابين الإقامة والإعاشة والعناية الاجتماعية والصحية المتكاملة. ولفت إلى أن المرض وراثي ينتج غالباً من زواج الأقارب، وغالباً ما يتوفى المصابون به في أعمار باكرة.

54 (III) Bullous Diseases:
1- Pemphigus Vulgaris. 2- Bullous Pemphigoid. 3- Benign Mucous Membrane Pemphigoid. 4- Bullous Lichen Planus. 5- Erythema Multiforme. 6- Stevens-Johnson Syndrome. 7- Epidermolysis Bullosa. 8- Dermatitis Herpetiformis.

55 Bullous Diseases: 8- Dermatitis Herpetiformis - Dermatitis herpetiformis, or Duhring–Brocq disease, is a chronic recurrent cutaneous bullous disease, rarely with oral involvement. -Etiology Unclear. Immunological and genetic factors, as well as gluten sensitivity, may be involved in the pathogenesis. Age: Between the ages of 20 and 50 years Sex: The disease is more common in men.

56 8- Dermatitis Herpetiformis
Desquamative Lesions 8- Dermatitis Herpetiformis Clinical Features: - The oral mucosa is affected in 5–10% of cases. - Oral manifestations follow the skin eruption, and present as maculopapular, erythematous, purpuric, and mainly vesicular lesions. -The vesicles appear in a cyclic pattern, and rupture rapidly, leaving shallow, painful ulcerations. -The tongue, buccal mucosa, and palate are more frequently involved. - Cutaneous lesions are always present and appear as erythematous papules or plaques followed by severe burning and pruritus and small vesicles that group in a herpeslike pattern. - The lesions exhibit exacerbations and remissions, and are commonly located symmetrically on the extensor surfaces.

57 Histopathological Descriptions:
Desquamative Lesions 8- Dermatitis Herpetiformis Histopathological Descriptions: - Sub-basilar separation with a subacute inflammatory infiltrate. Differential Diagnosis: - Bullous pemphigoid, cicatricial pemphigoid, linear IgA disease, pemphigus, herpetiform ulcers. Management: - Sulfones and sulfapyridines. A gluten-free diet may control the disease activity.

58 Bullous Diseases: 8- Dermatitis Herpetiformis

59 (IV) Desquamative Lesions:
1- Desquamative Gingivitis (Ginigivosis). 2- Erosive Lichen Planus. 3- Toothpaste Idiosyncrasy Lesions.

60 1- Desquamative Gingivitis
Desquamative Lesions 1- Desquamative Gingivitis A diffuse or patchy, often painful inflamed area of the gum caused by changes to the connective tissue as a result of the atrophy of epithelial cells. Also called gingivosis. Originally considered to be related to hormonal changes at menopause, since many of the patients are middle-aged women, DG is now recognized to be mainly a manifestation of a number of disorders ranging from vesiculobullous diseases to adverse reactions to a variety of chemicals or allergens. Age: Middle–aged adults Sex: Exclusively in females

61 1- Desquamative Gingivitis
Desquamative Lesions 1- Desquamative Gingivitis Clinical Features: It presents as erythema and edema of the marginal and attached gingiva. -The facial surface is more frequently affected than the lingual gingiva - Spontaneous desquamation of the epithelia, blister formation, and areas of superficial erosions are common.

62 1- Desquamative Gingivitis
Desquamative Lesions 1- Desquamative Gingivitis Clinical Features: - Characteristically, after mild pressure on the affected gingiva, desquamation of the epithelium or hemorrhagic blister formation usually occur. - The lesions may be either localized or generalized. Desquamative gingivitis may be the only oral manifestation or may be associated with additional oral lesions of the underlying chronic bullous dermatosis.

63 1- Desquamative Gingivitis
Desquamative Lesions 1- Desquamative Gingivitis -Histopathological Descriptions: - Like in BMMP, junctional separation occurs Differential Diagnosis: - BMMP, Necrotizing ulcerative gingivitis, plasma cell gingivitis, plaque related gingivitis, drug reactions, granulomatous gingivitis, oral psoriasis. - Management: - Good oral hygiene, avoidance of any mechanical pressure on the gingiva. Systemic treatment (corticosteroids, immunosuppressants, dapsone) depends on the identification of the underlying disease

64 (IV) Desquamative Lesions:
1- Desquamative Gingivitis (Ginigivosis). 2- Erosive Lichen Planus. 3- Toothpaste Idiosyncrasy Lesions.

65 2- Erosive Lichen Planus
Desquamative Lesions 2- Erosive Lichen Planus - Lichen planus is a relatively common chronic inflammatory disease of the oral mucosa and skin. Etiology Although the cause is not well known, T cell-mediated autoimmune phenomena are involved in the pathogenesis of lichen planus. Age: - Middle-aged individuals are more commonly affected. Sex: - the ratio of women to men ratio is 3 : 2

66 2- Erosive Lichen Planus
Desquamative Lesions 2- Erosive Lichen Planus Clinical Features: The erosive variety of LP is clinically characterized by a mixture of erosive erythematous areas and whitish pseudomembranes. When in the gingiva or the buccal mucosa, it tends to form small striations at the periphery of the lesion. Gingival erosive LP may affect the four quadrants and often is diagnosed as desquamative gingivitis. This term should be considered a transitory diagnosis until a biopsy and laboratory test confirm or rule out the diagnosis of LP.

67 2- Erosive Lichen Planus
Desquamative Lesions 2- Erosive Lichen Planus Clinical Features: Patients with this variety of LP complain of burning sensation especially when eating spicy foods or drinking alcohol, bleeding may also be present especially upon palpating or during tooth brushing. Erosive LP tends to remain for life and at times might become secondarily infected. When the oral manifestations are severe there is constant, mild to moderate pain as well as inability to eat properly.

68 2- Erosive Lichen Planus
Desquamative Lesions 2- Erosive Lichen Planus Histopathological Descriptions: - Histopathological examination is very helpful. Direct immunofluorescence can also be used, although the features are not specific. Differential Diagnosis: - The differential diagnosis should include: pemphigus vulgaris, mucous membrane pemphigoid, linear IgA disease, candidiasis and discoid lupus erythematosus Management: The prognosis of lichen planus is usually good, and malignant transformation (particularly of the erosive form) remains controversial. -Topical steroids (ointment in Orabase, intralesional injection), may be helpful. - Systemic steroids in low doses can be used in severe and extensive cases. -The topical use of antiseptic mouthwashes should be avoided.

69 (IV) Desquamative Lesions:
1- Desquamative Gingivitis (Ginigivosis). 2- Erosive Lichen Planus. 3- Toothpaste Idiosyncrasy Lesions.

70 3- Epithelial Peeling Desquamative Lesions
- Also called “Toothpaste Idiosyncrasy Lesions”. Epithelial peeling is a relatively common superficial desquamation (epitheliolysis) of the oral mucosa. It is caused by the direct irritating effect of toothpastes that contain sodium lauryl sulfate or pyrophosphates. The same phenomenon may be associated with chlorhexidine mouthwash. Sometimes the lesions are idiopathic.

71 3- Epithelial Peeling Desquamative Lesions Clinical Features:
Clinically, epithelial peeling presents as superficial painless white plaques or dots that can be easily lifted from the oral mucosa. The buccal mucosa, lip mucosa, and mucobuccal and mucolabial folds are more frequently affected. The lesions usually disappear when the individual stops using these toothpastes or mouthwashes. - The diagnosis is based entirely on the history and the clinical features.

72 3- Epithelial Peeling Desquamative Lesions Differential Diagnosis:
- Chemical burn, chronic biting, candidiasis, leukoplakia Management: - Discontinuation of responsible toothpastes or mouthwashes

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