Fig. 17.1
Upper panel demonstrates extensive superficial ulcers over the tongue in an elderly woman with severe oral lichen planus and limited skin lesions. Lower panel demonstrates diffuse gingival erosions in a patient with oral and cutaneous pemphigoid
Case
A patient presents with several-month history of painful oral erosions . Examination reveals erosions (not ulcers), involving any combination of the buccal mucosa, gingiva, tongue, and lips. Symptoms suggesting pharyngeal and/or laryngeal and/or esophageal involvement could be present.
Clinical Differential Diagnosis
The differential diagnosis includes
In case of acute onset strong consideration would be given to oral or mucosal erythema multiforme; hand, foot, and mouth disease, and other rare viral and bacterial oral infections. If the lesions are ulcers, then aphthosis is the preferred diagnosis.
erosive lichen planus (LP)
mucosal pemphigoid (MP) and
pemphigus vulgaris (PV).
Clinical Clues
The likelihood of making the right diagnosis solely based on clinical findings is at best moderate. Vesicles may rarely be seen in all three disorders. The degree of pain is probably worst in patients with PV, but cannot be relied upon in the clinical evaluation of patients.
Both erosive LP and PV favor the buccal mucosa. PV may be limited to the buccal mucosa, especially the posterior part. Erosive LP may be limited to the buccal mucosa, often favoring the anterior portion and occasionally extending to the corner of the mouth and lips.
Although MP has also traditionally been referred to as cicatricial pemphigoid because of the tendency for scarring, several patients with oral MP do not have evidence of scarring, so the diagnosis should be considered in the absence of scarring. Similarly, although erosive LP may be associated with striated whitish patches involving the surrounding mucosa, some patients with erosive LP have erosions without the characteristic surrounding whitish striations.
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