Oral lichen planus (OLP) is a common chronic disease of uncertain origin. Many patients with OLP are refractory to  all available therapies. The photodynamic therapy (PDT) was used as a possible alternative method in the treatment of  lichen planus. Two patients with five oral lichen planus lesions were treated using topical PDT mediated by methylene blue  (MB-PDT). The patients were followed up on sessions 3, 7, 15 days and 1 to 9 months after PDT. Clinical improvement  was achieved in four lesions. Two lesions showed complete remission, and another two lesions had about 50% clinically  improvement 3-9 months after a single session of PDT. No response detected in one lesion. MB-PDT blue seems to be  an effective alternative treatment for control of OLP. In our opinion, this preliminary result warrant further studies in  order to show the efficacy of MB-PDT in control of OLP for a longer period of time

Agha-Hosseini, Farzaneh

Arbabi-Kalati, Fateme

Ataie Fashtami, Leila

Esmaeeli Djavid, Gholamreza

Fateh, Mohsen

English

Repositori d'Objectes Digitals per a l'Ensenyament la Recerca i la Cultura

E126Oral Medicine and Pathology                                                       �                            Oral lichen planus with photodynamic therapy               Med Oral Patol Oral Cir Bucal 2006;11:E126-9.                                                 �   Oral lichen planus with photodynamic therapy Treatment of oral lichen planus with photodynamic therapy mediated methylene blue: A case reportFarzane Aghahosseini  1, Fateme Arbabi-Kalati  2, Leila Ataie Fashtami  3, Mohsen Fateh 1, Gholamreza Esmaeeli Djavid 4 (1) Associated Professor of Oral Medicine, Oral Medicine Department, Faculty of Dentistry, Tehran University of Medical Sciences (TUMS), Tehran(2) Assistant Professor of Oral Medicine, Oral Medicine Department, Faculty of Dentistry, Tabriz University of Medical Sciences, Tabriz(3) Assistant Professor of Dermatology, Iranian Center for Medical Laser (ICML), Academic Center for Education, Culture and Re-search (ACECR), Tehran(4) Researcher, Iranian Center for Medical Laser (ICML), Academic Center for Education, Culture and Research (ACECR), Tehran, IranCorrespondence:Dr. Farzane AghahosseiniOral Medicine Department, Faculty of Dentistry,Tehran University of Medical Sciences (TUMS), Tehran, Email: aghahoss@sina.tums.ac.irReceived: 30-09-2004   Accepted: 25-03-2005 Aghahosseini F, Arbabi-Kalati F, Fashtami LA, Fateh M, Djavid GE.  Treatment of oral lichen planus with photodynamic therapy mediated methylene blue: A case report. Med Oral Patol Oral Cir Bucal 2006;11:E126-9.© Medicina Oral S. L. C.I.F. B 96689336 - ISSN 1698-6946ABSTRACTOral lichen planus (OLP) is a common chronic disease of uncertain origin. Many patients with OLP are refractory to all available therapies. The photodynamic therapy (PDT) was used as a possible alternative method in the treatment of lichen planus. Two patients with five oral lichen planus lesions were treated using topical PDT mediated by methylene blue (MB-PDT). The patients were followed up on sessions 3, 7, 15 days and 1 to 9 months after PDT. Clinical improvement was achieved in four lesions. Two lesions showed complete remission, and another two lesions had about 50% clinically improvement 3-9 months after a single session of PDT. No response detected in one lesion. MB-PDT blue seems to be an effective alternative treatment for control of OLP. In our opinion, this preliminary result warrant further studies in order to show the efficacy of MB-PDT in control of OLP for a longer period of time.Key words: Oral lichen planus, photodynamic therapy, methylene blueIndexed in: -Index Medicus / MEDLINE  /  PubMed            -EMBASE, Excerpta Medica-Indice Médico Español                                                        -IBECS© Medicina Oral S.L. Email: medicina@medicinaoral.comINTRODUCTIONLichen planus (LP) is a relatively common, chronic derma-tologic disease that often affects the oral mucosa (1). OLP is reported to occur in 0.5 2.2% of the population, with a peak incidence in the 30-60 years age range and with a female predominance of 2:1. Unlike oral lesion, skin lesions are usually self  limited, lasting only one year or less. The etiology of LP involves a cell-mediated immunologically induced degeneration of the basal cell layer of epithelium (1). Two basic types of lesion occur: totally white (keratotic) and white (keratotic) with red (atrophic, erosive, bullous) (2). The occurrence of squamous cell carcinoma in most series ranges from 0.4 to 2% per a 5-year observation period (3). Treatment options of OLP are numerous, including topical and systemic agents (4). Because LP is an immunologically mediated condition, corticosteroids are recommended. Topical corticosteroids remain the mainstay of  therapy. However, therapeutic results are often disappointing.Photodynamic therapy (PDT) is an effective therapy for premalignant and malignant cutaneous lesions (5). It has also been reported as effective in treating psoriasis. We are reporting the results of oral lichen planus with Methylene blue mediated PDT in two cases.CASE REPORTSThe Patients were referred to the clinic of Iranian center for medical laser (ICML), ACECR, to undergo PDT. Methylene Oral Medicine and Pathology                                                       �                            Oral lichen planus with photodynamic therapy               Med Oral Patol Oral Cir Bucal 2006;11:E126-9.                                                 �   Oral lichen planus with photodynamic therapy E127blue (MB) was used as photosensitizer. It was prepared 0.05 gr per 100 cc. Ten minutes prior to laser irradiation, patients gargled MB for 5 minutes. A diode laser (Lumina®,Russia; 632 nm, CW) was used as light source. The lesions and 1 cm of their surrounding marginal zone were illuminated with a spot size of 2.5-3 cm2. Large lesions were illuminated with multiple spots. A fluence of 100 J/cm2 was used. The patients were followed up on sessions 3,7,15 days and 1 to 9 months after PDT. At the follow up sessions; lesions were examined to detect any residual lesion. Lesions were exactly measured and digital photographs were taken before PDT and at follow up session. Response rates were assessed clini-cally by amount of reduction in surface area of lesions.Patient 1A 52-year-old woman was referred to Oral Medicine De-partment of Tehran University by a specialist. Her medical history was positive for hypertension and taking propranolol and fluxitin.Her complaint was burning sense. Clinical examination revealed an atrophic area with white steria in her right man-dibular and left maxillary gingiva vestibule (Figure 1). Before treatment we use vital staining with toluidine blue for rule out of malignancy, then patient signed a written consent statement after receiving a full verbal explanation of treatment, including the potential benefits and risks of treatment. One week after a single session of PDT the lesions completely disappeared .and results of treatment were stable for 9 consecutively months of following.Patient 2A 60-year-old man with a 12-year history of  OLP had previously been treated with topical steroids. He had three keratotic lesions in left and right buccal mucosa and tongue.patient signed a written informed consent statement after receiving a full verbal explanation of treatment, including the potential benefits and risks of treatment (Figure 2). Fig. 1.  Atrophic and keratotic lichen planus lesion on the left upper gingival before photodynamic therapy (PDT) (A). Complete response after 9 months follow-up (B).Fig. 2. Keratotic lichen planus lesion on the left buccal mucosa before photodynamic therapy (PDT) (A). Partial response after 2 months follow-up (B).E128Oral Medicine and Pathology                                                       �                            Oral lichen planus with photodynamic therapy               Med Oral Patol Oral Cir Bucal 2006;11:E126-9.                                                 �   Oral lichen planus with photodynamic therapy He was treated as the same method as mentioned above. A week after treatment reduction size in right buccal lesion was about 40% and in left lesion 20%. Tongue lesion shows no sign of response, results of treatment were stable for 2 months of following.DISCUSSIONOral lichen planus (OLP) is a chronic inflammatory disease characterized by relapses and remissions. It is a cell-me-diated immune condition of unknown etiology, in which T lymphocytes accumulate beneath the epithelium of the oral mucosa and increase the rate of differentiation of the stratified squamous epithelium, resulting in hyperkeratosis and erythema with or without ulceration (1).There is currently no cure for OLP. Treatment is aimed primarily at reducing the length and severity of sympto-matic outbreaks. Topical steroids are the first choice agent for the treatment of symptomatic, active OLP (4). Other topical agents that have been used in cases resistant to to-pical steroids include retinoids, azathioprine, cyclosporine, tacrolimus, and mycophenolate mofetil. Oral and topical PUVA therapy with low-dose UVA is effective in treating OLP of the various forms, but it seems to have too many side-effects, mainly nausea and the potential for carcinoge-nicity (6). Topical application of psoralen is promising, but still experimental.The treatment of  dysplastic LP may require additional approaches directed at dysplastic/genetic changes that make use of current management for oral dysplasia, in addition to the anti-inflammatory management reviewed earlier (7). Current approaches to the management of oral dysplastic lesions include excision (laser or surgical), topical thera-pies including vitamin A and vitamin A analogues, topical chemotherapy (such as bleomycin), and systemic treatment with vitamin A analogues and other miscellaneous agents (7). The treatment of  symptomatic OLP, especially the erosive variant, represents a perplexing therapeutic cha-llenge. Despite numerous existing remedies, there are many treatment failures. One such promising modality is photodynamic therapy (PDT). PDT is a technique that uses a photosensitizing compound, activated at a specific wavelength of laser light, to destroy the targeted cell via strong oxidizers, which cause cellular damage, membrane lysis, and protein inactivation (8). PDT has been used with relative success in the field of oncology, notably in head and neck tumors (9). The exact mechanism of action of PDT is unclear. It would appear to act on hyperproliferating cells, such as are pre-sent in malignancies and psoriasis, with selective uptake of photosensitizers into these cells (10). It has been suggested that PDT may have immunomodulatory effects and may induce apoptosis in the hyperproliferating inflammatory cells which are present in psoriasis and lichen planus. This may reverse the hyperproliferation and inflammation of lichen planus. Nearly a century ago the antibacterial characteristics of the phenothiazine dye Methylene blue (MB) were described and attributed to its photodynamic 6 properties. MB itself  has been used in medical practice for more than 100 years and is recognized as having very low tissue toxicity. Clinical uses of MB include the treatment of ifosfamide encephalopathy, methemoglobinemia, urolithiasis, and cyanide poisoning (11). In addition, 0.5% MB is commonly used to stain the esophagus of patients with a history of Barrett’s esophagus and the bronchial lesions/pulmonary nodules of potential lung cancer patients (12). MB can be administered to human beings orally or intravenously in high doses without any toxic effects (13). Unlike other photosensitizers; MB can be administered topically and orally and it may be a preferred choice for superficial lesions in skin and oral cavity. The fact that MB has a strong absorption at wavelengths longer than 620 nm, where light penetration into tissue is optimal, has led to the using of MB as a promising candidate for PDT. Pervious studies showed ALA-mediated PDT that in addi-tion to being a somewhat painful therapy, the drug when topically applied does not penetrate deeply (14).In this study, five lesions had been treated with MB-mediated PDT. Two lesions completely resolved (Complete respon-se). A partial response (more than 50% improvement) was observed in two other lesions. There was no recurrence in improved lesions after 9 months follow-up. No improvement was observed in lesion on the tongue. We could find one report of the use of PDT for hypertro-phic lichen planus of the penis (15). Kirby and et al. used ALA-mediated PDT twice for treating of the lesion. The lesion had completely resolved after 4 weeks. At 6-month follow-up there was no recurrence. We believe this therapy may be effective in the treatment of oral lichen planus as well as neoplastic conditions. Further studies are needed to confirm the efficacy of PDT in the treatment of oral lichen planus. REFERENCES1. Dissemond J. Oral lichen planus: an overview. J Dermatolog Treat 2004;15:136-40.2. Scully C, Beyli M, Ferreiro MC, Ficarra G, Gill Y, Griffiths M et al. Update on oral lichen planus: etiopathogenesis and management. Crit Rev Oral Biol Med 1998;9:86-122.3. Carrozzo M, Gandolfo S. The management of oral lichen planus. Oral Dis 1999;5:196-205.4. Cerero R, Garcia-Pola MJ. Management of oral lichen planus. Med Oral 2004;9:124. 5. Roberts DJH, Cairnduff  F. Photodynamic therapy of primary skin cancer: a review. Br J Plast Surg 1995;48:360-70. 6. Kuusilehto A, Lehtinen R, Happonen RP, Heikinheimo K, Lehtimaki K, Jansen CT. An open clinical trial of a new mouth-PUVA variant in the treatment of oral lichenoid lesions. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;84:502-5.7. Epstein JB, Wan LS, Gorsky M, Zhang L. Oral lichen planus: progress in understanding its malignant potential and the implications for clini-cal management. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;96:32-7.8. Henderson BW, Dougherty TJ. How does photodynamic therapy work? Photochem Photobiol 1992;55:145-57. 9. Biel MA. Photodynamic therapy and treatment of head and neck neo-plasia. In: English G, editor. Otolaryngology. New York: Lippincott-Raven Publishers; 1996. p. 1-15. Oral Medicine and Pathology                                                       �                            Oral lichen planus with photodynamic therapy               Med Oral Patol Oral Cir Bucal 2006;11:E126-9.                                                 �   Oral lichen planus with photodynamic therapy E12910. Zeitouni NC, Oseroff  AR, Shieh S. Photodynamic therapy for nonmelanoma skin cancers. Current review and update. Mol Immunol 2003;39:1133-6.11. Kupfer A, Aeschilmann C, Wermuth B, Cerny T. Prophylaxis and reversal of  ifosfamide encephalopathy with methylene-blue. Lancet 1994;343:763-4. 12. Canto M-IF, Setrakian S, Petras RE, Blades E, Chak A, Sivak MV. Methylene blue selectively stains intestinal metaplasia in Barrett’s esopha-gus. Gastrointest Endosc 2000;44:1-7.13. AHFS Drug Information 2000.814. Allison RR, Downie GH, Cuenca R, Hu XH, Childs CJH, Sibata CH. Photosensitizers in clinical PDT. Photodiag Photodynamic 2004;1:27-42.15. Kirby B, Whitehurst C, Moore JV, Yates VM. Treatment of  li-chen planus of  the penis with photodynamic therapy. Br J Dermatol 1999;141:765-6. 

Treatment of oral lichen planus with photodynamic therapy mediated methylene blue : A case report

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Treatment of oral lichen planus with photodynamic therapy mediated methylene blue : A case report

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