British Journal of Dermatology (1976) 95, 9.
Carbohydrate metabolism in lichen planus N.J.LOWE,* A.G.GUDWORTH, S.A.CLOUGH AND M.F.BULLEN * Department of Dermatology, Liverpool Royal Infirmary, and Department of Medicine, University of JLiverpooI Accepted for publication 15 October 1975 SUMMARY
A study of forty patients with active lichen planus and a negative family history for diabetes showed th3t 42",, had unequivocally abnormal oral glucose tolerance. The pattern of insulin response to glucose is similar to that seen in typical mild maturity-onset diabetes. There was no association between the presence of glucose intolerance and the duration or type of lesions. None of the patients with glucose intolerance had demonstrable islet-cell antibodies. The aetiology of lichen planus is unknown. Many theories have been suggested including various metabolic disturbances (Cotton, Van Den Hurk & Vanderstaak, 1972; Black, 1972). There have been three previous reports suggesting an increased incidence of carbohydrate intolerance in this condition (Table i). In the two recent reports in the English literature, a positive family history of diabetes TABLE
Author Grinspan (1966) Jolly (1972) Powell et al. (1974)
I. Previous studies of glucose tolerance m lichen planus No. of patients
Type of lesion
Abnormal glucose tolerance
61 33 21
Oral Oral Cutaneous and mucosal
23 (37-7)' 28 (8g)t 13 C62)J
• Percentage in parentheses. t 21",, of the total—positive F.H. of diabetes mellitus. t 33% of the abnormal G.T.T. group—positive F.H. of diabetes mcUiliis.
was found in an appreciable proportion of cases. Furthermore, in seven of the twenty-one subjects studied by Powell et al. (1974) the presence of glucose intolerance was determined by the finding of a single elevated blood glucose level during a standard glucose tolerance test. The aim of the present investigation was to reassess more critically the incidence of carbohydrate intolerance in patients with active lichen planus (a) by selecting patients with no known family history of diabetes, and (b) byinvestigatingwhetherthere was any specific abnormality of insulin response to glucose in this condition. PATIENTS AND METHOD
A series of unrelated patients with active lichen planus who were attending dermatological outpatients departments in Liverpool were investigated. A careful history was taken to exclude any known history of diabetes in the family, and eight patients were thus excluded. A further nine patients were excluded because they were either taking systemic steroids or declined to have a glueose-tolerance test. This left a total of forty subjects who formed the basis of the present study. Oral glucose-tolerance testing was carried out under standard conditions following an overnight fast. Venous blood was collected at c (fasting) and 30, 60, 90 and 120 min after glucose. Blood glucose was estimated using a standard automated glucose-oxidase method, and plasma was
10
N.J.Lowe et al.
separated and stored at — 20'^C for the immunoassay of insulin at a later date using a modified HalesRandle double-antibody method. The criterion of abnormality of glucose tolerance employed was that of the Medical and Scientific Section of the British Diabetic Association (Fitzgerald & Keen, 1964), in which two or more venous blood glucose values were above the following limits: (i) A peak venous blood glucose of more than 160 mg/ioo ml, plus (2) a 2-h-bIood glucose of more than n o mg/ioo ml. The age range of the patients studied was 21-74 years (mean 48-1) There were equal numbers of males and females. Particular enquiry was also made into the duration of the skin lesions. Fourteen patients had cutaneous lesions only, three mucosal lesions only, and twenty-three had both cutaneous and mucosal lesions. As part of a larger study in which islet-cell-antibody titres have been investigated in diflferent types of diabetes mellitus (Lendrum ei al., 1976), serum from the patients who had a glucose-tolerance test in the present study were also screened. The techniques, have been described elsewhere (Lendrum, Walker & Gamble 1975). RESULTS
Of the forty subjects studied, five had clinical diabetes which had been confirmed by previous oral glucose-tolerance testing. One was on insulin therapy, and two were receiving an oral sulphonylurea drug. In four of these subjects, lichen planus had preceded the diagnosis of diabetes by between 6 months and 5 years and was still active. The patient who was insulin-dependent had been diabetic for 6 years prior to developing the skin lesions. The remaining thirty-five subjects with active lichen planus for widely varying lengths of time could be divided into three groups according to the results of the glucose-tolerance test: (i) Twelve were found to have unequivocal 'chemical diabetes', i.e. were asymptomatic but had abnormal glucose tolerance satisfying the minimum criteria listed above; (2) eighteen had unequivocally normal glucose tolerance; (3) five had a single abnormal blood glucose level and might possibly be regarded as 'borderline' chemical diabetics. In three of these, the 2-hblood glucose level exceeded 120 mg/ioo ml and the other two patients had a peak blood glucose level of 190 and 180 mg/ioo ml, respectively. The mean blood glucose and plasma insulin levels for these three groups are shown in Fig. i. The mean ages of the 'chemical diabetic' group and the normal glucose-tolerance group were 53-4 and 41-2 years respectively. There is a significant difference between the mean ages in these two groups (P
Carbohydrate metabolism in lichen planus N.J.LOWE,* A.G.GUDWORTH, S.A.CLOUGH AND M.F.BULLEN * Department of Dermatology, Liverpool Royal Infirmary, and Department of Medicine, University of JLiverpooI Accepted for publication 15 October 1975 SUMMARY
A study of forty patients with active lichen planus and a negative family history for diabetes showed th3t 42",, had unequivocally abnormal oral glucose tolerance. The pattern of insulin response to glucose is similar to that seen in typical mild maturity-onset diabetes. There was no association between the presence of glucose intolerance and the duration or type of lesions. None of the patients with glucose intolerance had demonstrable islet-cell antibodies. The aetiology of lichen planus is unknown. Many theories have been suggested including various metabolic disturbances (Cotton, Van Den Hurk & Vanderstaak, 1972; Black, 1972). There have been three previous reports suggesting an increased incidence of carbohydrate intolerance in this condition (Table i). In the two recent reports in the English literature, a positive family history of diabetes TABLE
Author Grinspan (1966) Jolly (1972) Powell et al. (1974)
I. Previous studies of glucose tolerance m lichen planus No. of patients
Type of lesion
Abnormal glucose tolerance
61 33 21
Oral Oral Cutaneous and mucosal
23 (37-7)' 28 (8g)t 13 C62)J
• Percentage in parentheses. t 21",, of the total—positive F.H. of diabetes mellitus. t 33% of the abnormal G.T.T. group—positive F.H. of diabetes mcUiliis.
was found in an appreciable proportion of cases. Furthermore, in seven of the twenty-one subjects studied by Powell et al. (1974) the presence of glucose intolerance was determined by the finding of a single elevated blood glucose level during a standard glucose tolerance test. The aim of the present investigation was to reassess more critically the incidence of carbohydrate intolerance in patients with active lichen planus (a) by selecting patients with no known family history of diabetes, and (b) byinvestigatingwhetherthere was any specific abnormality of insulin response to glucose in this condition. PATIENTS AND METHOD
A series of unrelated patients with active lichen planus who were attending dermatological outpatients departments in Liverpool were investigated. A careful history was taken to exclude any known history of diabetes in the family, and eight patients were thus excluded. A further nine patients were excluded because they were either taking systemic steroids or declined to have a glueose-tolerance test. This left a total of forty subjects who formed the basis of the present study. Oral glucose-tolerance testing was carried out under standard conditions following an overnight fast. Venous blood was collected at c (fasting) and 30, 60, 90 and 120 min after glucose. Blood glucose was estimated using a standard automated glucose-oxidase method, and plasma was
10
N.J.Lowe et al.
separated and stored at — 20'^C for the immunoassay of insulin at a later date using a modified HalesRandle double-antibody method. The criterion of abnormality of glucose tolerance employed was that of the Medical and Scientific Section of the British Diabetic Association (Fitzgerald & Keen, 1964), in which two or more venous blood glucose values were above the following limits: (i) A peak venous blood glucose of more than 160 mg/ioo ml, plus (2) a 2-h-bIood glucose of more than n o mg/ioo ml. The age range of the patients studied was 21-74 years (mean 48-1) There were equal numbers of males and females. Particular enquiry was also made into the duration of the skin lesions. Fourteen patients had cutaneous lesions only, three mucosal lesions only, and twenty-three had both cutaneous and mucosal lesions. As part of a larger study in which islet-cell-antibody titres have been investigated in diflferent types of diabetes mellitus (Lendrum ei al., 1976), serum from the patients who had a glucose-tolerance test in the present study were also screened. The techniques, have been described elsewhere (Lendrum, Walker & Gamble 1975). RESULTS
Of the forty subjects studied, five had clinical diabetes which had been confirmed by previous oral glucose-tolerance testing. One was on insulin therapy, and two were receiving an oral sulphonylurea drug. In four of these subjects, lichen planus had preceded the diagnosis of diabetes by between 6 months and 5 years and was still active. The patient who was insulin-dependent had been diabetic for 6 years prior to developing the skin lesions. The remaining thirty-five subjects with active lichen planus for widely varying lengths of time could be divided into three groups according to the results of the glucose-tolerance test: (i) Twelve were found to have unequivocal 'chemical diabetes', i.e. were asymptomatic but had abnormal glucose tolerance satisfying the minimum criteria listed above; (2) eighteen had unequivocally normal glucose tolerance; (3) five had a single abnormal blood glucose level and might possibly be regarded as 'borderline' chemical diabetics. In three of these, the 2-hblood glucose level exceeded 120 mg/ioo ml and the other two patients had a peak blood glucose level of 190 and 180 mg/ioo ml, respectively. The mean blood glucose and plasma insulin levels for these three groups are shown in Fig. i. The mean ages of the 'chemical diabetic' group and the normal glucose-tolerance group were 53-4 and 41-2 years respectively. There is a significant difference between the mean ages in these two groups (P
