Linear IgA bullous dermatosis mimicking oral lichen planus Sheevam Shah, MD, Brooke Mohr, MD, and Palak Parekh, MD
Linear IgA bullous dermatosis (LABD) is an autoimmune disease characterized by blisters on the skin and mucous membranes. Polycyclic, grouped bullae on cutaneous skin are the most characteristic clinical feature of LABD. Lesions are often indistinguishable from bullous pemphigoid or may resemble dermatitis herpetiformis. Oral lesions may be seen in 5% to 70% of patients with LABD, and in some cases, the oral mucosa may be the only area of involvement. Herein, we report a patient with LABD involving only the oral mucosa clinically. The entity histologically mimicked oral lichen planus, which challenges accurate diagnosis and emphasizes the importance of direct immunofluorescence.
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inear IgA bullous dermatosis (LABD) is an autoimmune disease that presents with bullae and blisters on the skin and is characterized on direct immunofluorescence by linear deposition of IgA along the basement membrane zone. Involvement of the oral, nasal, pharyngeal, or esophageal mucosa may also be present. Rarely, these mucosal lesions may be the only clinical manifestation.
Figure 1. Eroded area on buccal mucosa with overlying whitish change.
CASE STUDY A woman in her late 50s presented to the dermatology clinic after being referred by her dentist for evaluation of buccal mucosal changes of her right posterior mouth. The patient reported mild pain in the area over the previous 2 weeks. She denied any previous treatments for the oral changes. She also denied recent initiation of any new medications or recent invasive dental work. Her medical history was significant only for a 6 pack-year history of smoking. Physical exam revealed a white, reticular plaque on the right buccal mucosa with erosions (Figure 1). Incisional biopsy demonstrated a lichenoid inflammatory infiltrate (Figure 2). Direct immunofluorescence showed linear deposition of IgA (Figure 3). Figure 2. Band-like lichenoid inflammatory infiltrate.
DISCUSSION Polycyclic, grouped bullae on cutaneous skin—which have been described as a “cluster of jewels” or “string of pearls”—are the most characteristic clinical feature of LABD. Clinical diagnosis of LABD is difficult due to its similarity to bullous pemphigoid and dermatitis herpetiformis. Characteristic histological features include a subepidermal blister with a prominent neutrophilic 360
From Texas A&M Health Science Center College of Medicine (Shah, Parekh) and Department of Dermatology, Scott & White Memorial Hospital (Shah, Mohr, Parekh), Temple, Texas. Corresponding author: Sheevam Shah, MD, Scott & White Dermatology Clinic – Temple Northside, 409 West Adams Avenue, Temple, TX 76501 (e-mail: sheevam. [email protected]). Proc (Bayl Univ Med Cent) 2017;30(3):360–361
Figure 3. Linear IgA deposition along dermal-epidermal junction.
infiltrate. A few prior cases of oral LABD with a lichenoid histology mimicking lichen planus have been reported (1). Two types of LABD have been identified, drug-induced and spontaneous (2). In drug-induced LABD, lesions tend to be more severe than in the spontaneous form. Various case reports have described drug-induced LABD presenting as toxic epidermal necrolysis (3). Commonly implicated drugs include vancomycin (4), beta-lactam antibiotics, captopril, and nonsteroidal antiinflammatory drugs. The differential diagnosis for reticular changes of the buccal mucosa includes primarily lichen planus, lichenoid drug reaction, and contact allergy. Biopsy in our patient revealed a lichenoid inflammatory infiltrate, compatible with lichen planus. She was not taking any medications. Furthermore, she denied any recent dental work, minimizing the possibility of a contact allergy to components of her fillings in nearby teeth.
July 2017
Establishing the correct diagnosis can guide appropriate treatment. In recent years, indirect and direct immunofluorescence have emerged as tools that can be used in conjunction with histopathology in making these difficult diagnoses (5). It is important to consider oral LABD as a differential in cases of clinically suspected oral lichen planus, especially those that fail to respond to initial therapies. Thus, direct immunofluorescence studies should be pursued to distinguish between the two entities and guide appropriate treatment. Dapsone has been reported as a successful treatment option for management of oral LABD in cases refractory to topical and systemic steroids. Early diagnosis and management of LABD can induce rapid improvement and may decrease the incidence of relapse after treatment withdrawal (6). 1. 2. 3.
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5.
6.
Ingen-Housz-Oro S. [Linear IgA bullous dermatosis: a review]. Ann Dermatol Venereol 2011;138(3):214–220. Selvaraj PK, Khasawneh FA. Linear IgA bullous dermatosis: a rare side effect of vancomycin. Ann Saudi Med 2013;33(4):397–399. Cohen DM, Bhattacharyya I, Zunt SL, Tomich CE. Linear IgA disease histopathologically and clinically masquerading as lichen planus. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88(2):196–201. Chanal J, Ingen-Housz-Oro S, Ortonne N, Duong TA, Thomas M, Valeyrie-Allanore L, Lebrun-Vignes B, Andre C, Roujeau JC, Chosidow O, Wolkenstein P. Linear IgA bullous dermatosis: comparison between the drug-induced and spontaneous forms. Br J Dermatol 2013;169(5):1041– 1048. Fukuda A, Himejima A, Tsuruta D, Koga H, Ohyama B, Morita S, Hashimoto T. Four cases of mucous membrane pemphigoid with clinical features of oral lichen planus. Int J Dermatol 2016;55(6):657–665. Daniels TE, Quadra-White C. Direct immunofluorescence in oral mucosal disease: a diagnostic analysis of 130 cases. Oral Surg Oral Med Oral Pathol 1981;51(1):38–47.
Linear IgA bullous dermatosis mimicking oral lichen planus
361
Linear IgA bullous dermatosis (LABD) is an autoimmune disease characterized by blisters on the skin and mucous membranes. Polycyclic, grouped bullae on cutaneous skin are the most characteristic clinical feature of LABD. Lesions are often indistinguishable from bullous pemphigoid or may resemble dermatitis herpetiformis. Oral lesions may be seen in 5% to 70% of patients with LABD, and in some cases, the oral mucosa may be the only area of involvement. Herein, we report a patient with LABD involving only the oral mucosa clinically. The entity histologically mimicked oral lichen planus, which challenges accurate diagnosis and emphasizes the importance of direct immunofluorescence.
L
inear IgA bullous dermatosis (LABD) is an autoimmune disease that presents with bullae and blisters on the skin and is characterized on direct immunofluorescence by linear deposition of IgA along the basement membrane zone. Involvement of the oral, nasal, pharyngeal, or esophageal mucosa may also be present. Rarely, these mucosal lesions may be the only clinical manifestation.
Figure 1. Eroded area on buccal mucosa with overlying whitish change.
CASE STUDY A woman in her late 50s presented to the dermatology clinic after being referred by her dentist for evaluation of buccal mucosal changes of her right posterior mouth. The patient reported mild pain in the area over the previous 2 weeks. She denied any previous treatments for the oral changes. She also denied recent initiation of any new medications or recent invasive dental work. Her medical history was significant only for a 6 pack-year history of smoking. Physical exam revealed a white, reticular plaque on the right buccal mucosa with erosions (Figure 1). Incisional biopsy demonstrated a lichenoid inflammatory infiltrate (Figure 2). Direct immunofluorescence showed linear deposition of IgA (Figure 3). Figure 2. Band-like lichenoid inflammatory infiltrate.
DISCUSSION Polycyclic, grouped bullae on cutaneous skin—which have been described as a “cluster of jewels” or “string of pearls”—are the most characteristic clinical feature of LABD. Clinical diagnosis of LABD is difficult due to its similarity to bullous pemphigoid and dermatitis herpetiformis. Characteristic histological features include a subepidermal blister with a prominent neutrophilic 360
From Texas A&M Health Science Center College of Medicine (Shah, Parekh) and Department of Dermatology, Scott & White Memorial Hospital (Shah, Mohr, Parekh), Temple, Texas. Corresponding author: Sheevam Shah, MD, Scott & White Dermatology Clinic – Temple Northside, 409 West Adams Avenue, Temple, TX 76501 (e-mail: sheevam. [email protected]). Proc (Bayl Univ Med Cent) 2017;30(3):360–361
Figure 3. Linear IgA deposition along dermal-epidermal junction.
infiltrate. A few prior cases of oral LABD with a lichenoid histology mimicking lichen planus have been reported (1). Two types of LABD have been identified, drug-induced and spontaneous (2). In drug-induced LABD, lesions tend to be more severe than in the spontaneous form. Various case reports have described drug-induced LABD presenting as toxic epidermal necrolysis (3). Commonly implicated drugs include vancomycin (4), beta-lactam antibiotics, captopril, and nonsteroidal antiinflammatory drugs. The differential diagnosis for reticular changes of the buccal mucosa includes primarily lichen planus, lichenoid drug reaction, and contact allergy. Biopsy in our patient revealed a lichenoid inflammatory infiltrate, compatible with lichen planus. She was not taking any medications. Furthermore, she denied any recent dental work, minimizing the possibility of a contact allergy to components of her fillings in nearby teeth.
July 2017
Establishing the correct diagnosis can guide appropriate treatment. In recent years, indirect and direct immunofluorescence have emerged as tools that can be used in conjunction with histopathology in making these difficult diagnoses (5). It is important to consider oral LABD as a differential in cases of clinically suspected oral lichen planus, especially those that fail to respond to initial therapies. Thus, direct immunofluorescence studies should be pursued to distinguish between the two entities and guide appropriate treatment. Dapsone has been reported as a successful treatment option for management of oral LABD in cases refractory to topical and systemic steroids. Early diagnosis and management of LABD can induce rapid improvement and may decrease the incidence of relapse after treatment withdrawal (6). 1. 2. 3.
4.
5.
6.
Ingen-Housz-Oro S. [Linear IgA bullous dermatosis: a review]. Ann Dermatol Venereol 2011;138(3):214–220. Selvaraj PK, Khasawneh FA. Linear IgA bullous dermatosis: a rare side effect of vancomycin. Ann Saudi Med 2013;33(4):397–399. Cohen DM, Bhattacharyya I, Zunt SL, Tomich CE. Linear IgA disease histopathologically and clinically masquerading as lichen planus. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88(2):196–201. Chanal J, Ingen-Housz-Oro S, Ortonne N, Duong TA, Thomas M, Valeyrie-Allanore L, Lebrun-Vignes B, Andre C, Roujeau JC, Chosidow O, Wolkenstein P. Linear IgA bullous dermatosis: comparison between the drug-induced and spontaneous forms. Br J Dermatol 2013;169(5):1041– 1048. Fukuda A, Himejima A, Tsuruta D, Koga H, Ohyama B, Morita S, Hashimoto T. Four cases of mucous membrane pemphigoid with clinical features of oral lichen planus. Int J Dermatol 2016;55(6):657–665. Daniels TE, Quadra-White C. Direct immunofluorescence in oral mucosal disease: a diagnostic analysis of 130 cases. Oral Surg Oral Med Oral Pathol 1981;51(1):38–47.
Linear IgA bullous dermatosis mimicking oral lichen planus
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