International Journal of Pathology Research

International Journal of Pathology Research

www.pathologyjournal.in
E-ISSN: 2664-5505, P-ISSN: 2664-5750
Received Date: 01-11-2018 Accepted Date: 06-12-2018
Volume 2; Issue 1; Janvary 2019; page No. 01-04

Oral lichen Planus superimposed with candidiasis: A neglected, potentially dangerous combination
Pavan K Tupakula1, Ankita Kar2*, Ramya A Ganesh3, Rakesh Nagaraju4, Mahantesha S Chakrasali5, Ashwini S Gowda6,
Sujatha S Reddy7
1, 2, 4, 7
Department of Oral Medicine and Radiology, Faculty of Dental Sciences, Ramaiah University of Applied Sciences, Karnataka, India
3, 5, 6
Department of Periodontology and Implantology, Faculty of Dental Sciences, Ramaiah University of Applied Sciences, Karnataka, India

Abstract
Lichen planus has been defined as a chronic systemic disease which commonly involves the oral mucosa. Lichen planus may present as
desquamative gingivitis (DG), clinically appearing as a red, tender, friable and glazed gingiva. Though relatively common, oral lichen
planus (OLP) has always been a matter of controversy, primarily in relation to its etiopathogenesis and possible potential for malignant
transformation. Histologically lichen planus has features of hyperkeratinisation which possibly has increased predisposition for candidal
infection. Often the erythematous areas in OLP manifests as the disease itself or a result of superimposed candidiasis, both of which are
concomitant with morbidity as soreness and pain. Hence, the objective of this paper is to report a case of OLP associated with candidal
infection and to discuss its potential for malignant transformation.

Keywords: candida albicans, candidiasis, diagnosis, gingivitis, lichen planus, oral

Introduction
“Desquamative gingivitis” was first described by Prinz in 1932
which presents with areas of desquamation, erythematous and
erosive regions, often with blistering of attached and marginal
gingiva [1]. The adult age group are usually affected. The
commonest cause of desquamative gingivitis is oral lichen planus
and also due to an abnormal response to bacterial plaque, aging,
allergic reaction, chronic infections, autoimmune diseases or
idiopathic [2]. OLP is a chronic inflammatory oral mucosal
disease with an unknown aetiology. It is believed by most
researchers that immunologic factors are involved. World Health
Organization introduced OLP as a complication, which increases
the potential for malignancy. Recently, investigators have
focused on the existence of pathogenic microorganisms, such as
Candida albicans in patients with refractory OLP and
leukoplakia. Candidiasis is an infection cause by candida; mainly
C. albicans which is seen in approximately 37% of OLP lesions
[3]
. Candida albicans could become opportunistic pathogen when
the conditions of oral environment, i.e. decrease of oral immune
response or the oral microorganism ecosystem change. OLP
symptoms may be exacerbated by candidal overgrowth or
infection [4]. Numerous treatment modalities have been proposed
(each with pertinent side effect) even though disorders of immune
system are considered as common etiologic factors in OLP [3].
Therapeutic management of OLP poses considerable problems to
the dental professional. Theoretically, in some cases of OLP, the
use of antifungal agents can diminish the potential of C. albicans
to produce carcinogen like N nitrosobenzylmethyl-amine [4, 3]. It
is challenging to correlate whether there is a synergistic pre-
malignant effect in case of exposure to potentially carcinogenic
substances (contributing external risk factors) and persistence of
OLP (intrinsic risk factor). Here with we present a case,
emphasising on the increased malignant potential of OLP due to
superimposed candidiasis.
Case Report
A female patient aged 55 years reported to the department of Oral
Medicine and Radiology with the chief complaint of itching and
burning sensation in her upper & lower gums since three months.
On eliciting the history, patient was apparently well 3 months
back following which she developed burning sensation in her
gums. It was associated with pain which aggravated on having
spicy & hot food/ beverages and during daily oral hygiene
procedures. The symptoms persisted for 30 minutes and
gradually subsided following the removal of the stimulant.
Patient had visited a dentist with the same complaint three
months back where she was advised to apply:
 Rexidin- M gel BID x 15 days
 Kenocort 0.1% BID x 15 days
Following the application of the medication, there was mild
decrease in the symptoms which backslid after 1 month. She
visited the dental practitioner again, who performed oral
prophylaxis and changed her medication as follows:
 Mucopain gel BID x 8 days
 Dentogel BID x 8 days
Since patient did not have relief of symptoms, she was referred
to our hospital. On clinical examination: the patient presented
with three different forms of lesions intraorally. Inspection of the
lesions revealed erythematous, glazed, friable buccal and labial

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gingiva of maxillary and mandibular arch. Erosion of the surface prodrug 5-aminolevulinic acid (ALA) cream (5%, w/w). ALA
epithelium over the lesion was noted suggestive of desquamation cream was then applied evenly to the site. ALA-applied area was
of the gingiva (fig 1 A & B). On the maxillary attached gingiva covered with a black sheet for light protection. After 1 hour of
i.r.t. 21, 22, a diffuse whitish plaque was noted measuring application, excess ALA was removed from the lesions and light
approximately 1 x 1.5 cms in size at its greatest diameter. The irradiation was carried out using a 660nm diode laser. The
lesion had well defined boundaries. On palpation, it was treatment was repeated at two-week intervals, twice in a week
scrappable and non-tender. No bleeding from the site was noticed until complete remission was achieved. The assessment of
(Fig 1 B). Multiple irregular whitish striae noticed interlacing clinical improvement and adverse reactions was noted before and
each other surrounded by hyperpigmention on the right buccal after each treatment.
mucosa, measuring approximately 4 x 5cms in size at its greatest
diameter. Bilaterally in buccal mucosa, the lesion extended
anteriorly 1cm away from the commissure of the lip up to
retromolar trigome region posteriorly. The surrounding mucosa
appeared to be erythematous. On palpation, it was non-
scrappable and non-tender. No bleeding from the site was noticed
(fig 1 C & D). Based on the history and clinical examination a
provisional diagnosis of oral lichen planus superimposed with
pseudomembranous candidiasis was considered. Exfoliative
cytology was performed; the smears were taken from the
maxillary and mandibular labial mucosa, buccal mucosa (a) (b)
bilaterally and over the dorsum of the tongue. Patient was advised Fig 1: A & B Erosion of the surface epithelium over the lesion was
routine haematological investigation and since the patient did not noted suggestive of desquamation of the gingiva
present with any clear immune-compromised state (for candidal
infection); she was advised for a HIV test. Following this, patient
underwent supra-gingival scaling. A topical anaesthetic (annabel
gel) was prescribed which in turn caused hypersensitivity
reactions. Therefore she was advised to discontinue Annabel gel
and was replaced with normal saline mouth wash as alcohol base
mouthwash would worsen her symptoms. All her haematologic
investigatory reports were normal. Cytology impression revealed
class I cytological smear with inflammation and positive for
candida. CANDID-B (clotrimazole + beclomethasone) powder (c) (d)
was added to her prescription and patient was instructed to use
the powder by applying in the occlusal splint/ medication tray Fig 1: C & D multiple irregular whitish striae noticed interlacing each
other surrounded by hyperpigmention on the right buccal mucosa and
thrice daily for an hour for 2 weeks (Fig 2). On follow up, there
left buccal mucosa
was marked decrease in both signs and symptoms and no fresh
complaints were observed (Fig 3 A, B, C & D). Incisional biopsy
was performed and histopathological characteristics revealed a
fragment of oral mucosa lined by stratified squamous epithelium,
with areas of para or orthokeratosis, spongiosis, acanthosis, focus
of hydropic degeneration and degeneration of the basement layer.
Fibrous connective tissue with variable density was seen in the
underlying lamina propria which also presented with an intense
inflammatory infiltrate, mainly lymphocytic, situated in the
subepithelial region and arranged in a band-like pattern.
Dysplastic alterations were also noted in the basilar and
parabasilar portions of the epithelium indicative of mild to
moderate dysplasia. Patient was advised application of TESS
ointment (triamcinolone acetonide 0.1%) twice daily for 15 days
and recalled after a month. The symptoms had subsided but there
was no complete remission of the disease. A Visual Analog Score
(VAS) for each site was noted to assess pain and burning
sensation individually. Therefore Photodynamic therapy (PDT)
was advised for the patient since it has been proven to be effective
in the treatment of premalignant and malignant cutaneous lesions.
The lesions were first cleaned with normal saline solution
followed by topical administration of PDT mediated with Fig 2: Occlusal splint

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(a)
(c)
Fig 3: A, B, C & D Marked decrease in erythematous areas and healing of signs of lichen planus noted on the right and left
Discussion
The rate of malignant transformation of OLP ranges from 0.04%
and 1.74 % in a year. The highest chance of malignancy is seen
with atrophic, erosive or ulcerative lesions. It has been postulated
that atrophic, erosive and ulcerative lesions predispose the
mucosa to damage from carcinogenic agents but patients who
develop carcinoma, lack a history of consumption of alcohol or
tobacco habits or there might be a chance of other extrinsic
factors involved.
Candida is a known inhabitant of oral cavity and also develops
secondary to corticosteroid therapy; hence the role of candida can
be another cause of development of malignancy in patients
affected with OLP [5].
Oral Candida is “opportunistic pathogens”. Depending on the
host defence mechanisms or local oral microenvironment,
Candida can transform from a harmless commensal to the
pathogenic organism causing oral mucosal infection6. There is a
strong controversy in scientific literature regarding the
colonization of candida in OLP lesions. The significance of
fungal infections in OLP lesions is underestimated as the
infection may not be obvious clinically and many a times it is a
subclinical infection which is detected either on biopsy or
microscopic examination [7]. Clinically OLP is originally
classified into seven forms: reticular, plaque, papular, bullous,
erosive, atrophic, and ulcerative [5]. Role of Candida in lichen
planus is still unclear. The ability of C. albicans to colonize,
penetrate, and damage host tissues depend on the imbalance
between C. albicans virulence factors and host defences, often
due to specific defects in the immune system [8]. Several cell
surface proteins called adhesins recognizing host molecules are
identified. They adhere to the cell surface and then phenotypic
switching from the yeast form to hyphae form. Candida can then
produce carcinogenic compounds, like nitrosamines, N-
nitrosobenzylmethylamine. Strains with high nitrosation
potential are often isolated from lesions with more advanced
precancerous changes. The yeast cells in such cases extends from
the mucosal surface to the deeper epithelial cell layers
representing transport and deposition of precursors like
nitrosamines to deeper layers [6]. This shows that certain strains
(b)
(d)
of C. albicans play a key role in the development of dysplasia, as
was noted in our case.
Lodi et al. 2005 [4] discussed in a consensus meeting over the
controversial aspects of OLP; it was stated that the clinical
symptoms of OLP are often exacerbated by candidal overgrowth
or infection, while the use of anti-fungal therapy on erosive oral
lichen planus (EOLP) with Candida can change the lesions to the
reticular form. Theoretically the usage of anti-fungal treatment in
some cases of OLP could decrease the potential of Candida
albicans to produce carcinogenic N-nitrosobenzylmethylamine.
Harijanti et al. [9] published a case report in 2006 where a 49 years
old female patient had clinical and mycological evidence of
thrush (Oral acute pseudomembrane candidiasis). Also on
clinical examination, hyperkeratotic lesion (Wickham’s striae)
was noted, and histopathological test confirmed as OLP. The case
report suggested that the first treatment should be given
antimycotic if the mycological test of candidiasis showed
positive result, which was followed in our case.
Mehdipour et al in 2009 [3] investigated the prevalence of candida
species in the erosive OLP lesions. On comparison of healthy
individuals and patients with EOLP, no significant difference was
noted regarding presence of candida species. Therefore it was
concluded that candida is not confirmed as an etiologic factor for
EOLP.
Santhosh gowdu et al. [7] conducted a study in 2012, where 34
OLP patients were subjected to clinical, mycological and
histopathological investigations for presence of candida
organisms which resulted in prevalence of candida in 44% of the
subjects and they concluded that treatment with antifungals can
reduce the size and patterns of OLP lesions. But their study did
not show any statistical significance among OLP and Candida as
44 % was also seen in normal mucosa.
In another study by Arora et al. [10] in 2016, 80 patients were
enrolled with 64 non-erosive and 16 erosive OLP patients.
Results showed that Candida albicans was common among non-
erosive group and other forms of Candida such as C. glabrata and
C. krusei were predominant among erosive group of OLP
patients. Rodriguez‑Archilla et al. in 2018 [11] stated in their meta-
analysis that candida detection was greater in patients with OLP,
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although no statistically significant relationship was found. In N-nitrosobenzylmethylamine. Carcinogenesis. 1987;

their analysis 29.1% of OLP were infected by Candida species. 8(10):1543-8.
They concluded that oral cancer increased the risk of Candida 9. Harijanti K. Candidosis on oral lichen planus. Dent J. 2006;
infection by 4.92 folds however; OLP patients did not present a 39(2):80-4.
raised risk than controls for Candida infection. 10. Arora S, Verma M, Gupta SR, Urs AB, Dhakad MS, Kaur R.
et al Phenotypic variability and therapeutic implications of
Conclusion Candida species in patients with oral lichen planus. Biotech
Hence to conclude, OLP is a common oral mucosal disease Histochem. 2016; 91(4):237-41.
process encountered in clinical practice. Various literatures in the 11. Rodriguez-Archilla A, Alcaide-Salamanca MJ. Candida
past state the possible role of Candidal infection in potentially species detection in potentially malignant and malignant
malignant lesions of the oral mucosa such as OLP. However a disorders of the oral mucosa: A meta-analysis. J Dent Res
statistical significant correlation with candida and OLP has not Rev. 2018; 5(2):35.
been established and their correlation still remains controversial.
Since candidal infection is known to produce carcinogens, N-
nitrosobenzylmethylamine, its association with known OPMD
(OLP) creates an alarming situation of dangerous combination.
Diagnosing this combination with relevant investigations using
multiple tests with high precision, such as DNA analysis, are
required to elucidate the exact role of Candida in progression of
OLP. Finally the clinician, while formulating the treatment plan
should also focus on the eliminating the microbial component of
OLP.

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