|LETTER TO EDITOR
|Year : 2019 | Volume
| Issue : 2 | Page : 110-112
Good response to metronidazole in a case of erosive genital lichen planus
Vidya Kharkar, Anuja Sunkwad
Department of Dermatology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
|Date of Web Publication||16-Dec-2019|
Dr. Anuja Sunkwad
Room Number 1213, UGPG Hostel, KEM Hospital Campus, Parel, Mumbai - 400 012, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kharkar V, Sunkwad A. Good response to metronidazole in a case of erosive genital lichen planus. Indian J Drugs Dermatol 2019;5:110-2
|How to cite this URL:|
Kharkar V, Sunkwad A. Good response to metronidazole in a case of erosive genital lichen planus. Indian J Drugs Dermatol [serial online] 2019 [cited 2020 Jul 3];5:110-2. Available from: http://www.ijdd.in/text.asp?2019/5/2/110/272961
Lichen planus (LP) is an immunologically mediated inflammatory disorder involving skin, hair, nail, and mucous membrane. It affects all irrespective of age, sex, and geographic location. Although the oral mucosa is the most common mucosa involved in LP, genital mucosal erosions are also seen in elderly females, which is known as vulvovagino-gingival syndrome. Here, we are sharing our experience of isolated genital erosive LP treated with metronidazole 500 mg twice daily for 3 months.
A 35-year-old married female, teacher by occupation presented in the outpatient department (OPD) with complaints of extensive painful erosions over perineal area since 18 months.
The patient reported that she was apparently all right one and ½ years back when she had noticed a sudden onset of painful, mildly itchy erosions with surrounding erythema over labia minora and mucosal aspect of labia majora. The erosions were gradually increasing in size and number.
The patient had consulted many dermatologists for these same complaints. Without any specific diagnosis, she received multiple modalities of treatment, which included antifungal medication, antiviral medication for an extended period without any significant relief in symptoms. The lesions were persistent even with the above treatment. When the patient presented to us, she was on suppressive therapy for recurrent genital herpes, i.e., taking 500 mg valacyclovir for the past 6 months without any marked improvement in symptoms.
On clinical examination, there were multiple superficial, bilaterally symmetrical, ill-defined, painful, extensive erosions involving labia majora, labia minora, vagina extending up to groins and perianal area. Erosions were covered with yellowish-white slough at few places [Figure 1] and [Figure 2].
The patient was investigated thoroughly. Tzanck smear did not show any acantholytic cells or multinucleate giant cells. Gram stain was negative for candida. Routine investigations showed iron deficiency anemia with hemoglobin: 5.3 gm%, total leukocyte count: 7170/mm3, platelet: 5 lakh/mm3, hypochromia and microcytosis seen on peripheral smear, fasting BSL: 72 mg%, postprandial BSL: 107 mg%, HBA1C was 4.1, immunoglobulin-M titers for herpes simplex virus 1 and 2 were negative. Her liver function test, renal function test, urine, and stool routine examination did not show any abnormality. The patient was found nonreactive for venereal disease research laboratory, HIV, hepatitis B, and hepatitis C antibodies. Her husband's investigations were normal. Considering the chronicity of the disease, we performed a 4 mm skin punch biopsy from an erosion over the labia. Histopathology showed loss of superficial layers of epidermis, basal layer showed vacuolar interface, and few necrotic keratinocytes. Papillary dermis showed moderately dense lymphoplasmacytic band of infiltrate and melanin incontinence [Figure 3] and [Figure 4]. On the basis of clinico-histopathological findings, the final diagnosis of erosive vulvovaginal LP was confirmed.
|Figure 3: Moderately dense band of lymphoplasmacytic infiltrate in the papillary dermisq|
Click here to view
|Figure 4: Higher magnification shows melanin incontinence with focal basal cell vacuolization|
Click here to view
The patient received 12 weeks of therapy with metronidazole 500 mg twice daily, along with oral zinc supplements and topical 2% sodium fusidate ointment. The patient was assessed on OPD basis every 3 weekly, and she showed marked improvement in her symptoms and healing of erosions on the first visit and complete symptomatic relief at 6 weeks. All the erosions healed with brownish hyperpigmentation [Figure 5]. There was no recurrence of lesions on the follow-up of the patient for 4 months.
|Figure 5: Symptomatic relief with complete healing of erosions by 3 weeks of treatment|
Click here to view
Erosive LP of vulva and autoimmune diseases has temporal association., Anti-basement membrane zone antibodies chiefly targeting BP180 are present in sera of 61% of patients with erosive LP. One study found such patients are more likely to have autoimmune disorders and circulating antibodies; particularly antinuclear antibodies (ANA) (25%) and antithyroid antibodies (19%). In view of this, the patient was advised to do ANA, BP180 antigen, and anti-thyroid peroxidase, which was negative. Infections such as hepatitis C virus, human papillomavirus, vaccination with hepatitis B vaccine, oxidative stress, and psychological stress are other etiological factors for LP.,,
Oral or intralesional steroids, along with antihistaminics and topical care, are the first line of treatment for erosive LP; however, relapses are common with the use of corticosteroids. Considering the possibility of superadded bacterial skin infection, we did not add steroid in the first visit and started the patient on metronidazole 500 mg twice daily with topical sodium fusidate ointment to which the patient showed significant improvement after 3 weeks.
Metronidazole is a synthetic nitroimidazole antibiotic drug which has anti-inflammatory and immunomodulatory effect; however, the exact mechanism of action is not known., It induces significant decrease in delayed type of hypersensitivity reaction, phagocytic activity, and tumor necrosis factor-alpha secretion by macrophages., Metronidazole is used in many dermatological conditions.
This article here highlights the effectiveness of metronidazole in genital erosive LP and the fact that the effect started as early as 10 days of treatment, and significant improvement was seen by 3 weeks without any relapse or recurrence.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
We would like to thank the Department of Dermatology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Madnani N. Vulvar Lichen Planus. In: Khopker U, Valia A, editors. Lichen Planus. 1st
ed. New Delhi: Jaypee Brothers; 2013. p. 116-22.
Khopker U, Valia A. Lichen Planus. 1st
ed. New Delhi: Jaypee Brothers Medical Publishers(p) Ltd; 2013.
Sharma N, Malhotra SK, Kuthial M, Chahal KS. Vulvo-vaginal ano-gingival syndrome: Another variant of mucosal lichen planus. Indian J Sex Transm Dis AIDS 2017;38:86-8.
Pradhan S, Madke B, Kabra P, Singh AL. Anti-inflammatory and immunomodulatory effects of antibiotics and their use in dermatology. Indian J Dermatol 2016;61:469-81.
] [Full text]
Tambe S, Patil P, Modi A, Jerajani H. Metronidazole as a monotherapy in the management of granulomatous cheilitis. Indian J Dermatol Venereol Leprol 2018;84:491-5.
] [Full text]
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]