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What is oesophageal lichen planus (ELP)?
Lichen planus is an inflammatory, multi-system disorder (affects multiple parts of the body). Lichen planus can affect the mouth, skin and/or genital areas. When it affects the oesophagus, we term this oesophageal lichen planus.
Oesophageal lichen planus is under-recognised and frequently mistaken even by specialists for more common conditions such as acid reflux (GORD/GERD), candida (thrush) or non-specific “oesophagitis”. However, the treatment of oesophageal lichen planus is quite different to these other more common conditions, making correct diagnosis crucial.
How common is oesophageal lichen planus?
Data on oesophageal lichen planus prevalence in the population is relatively lacking. It is considered a relatively uncommon diagnosis, though the caveat is that it is almost certainly underdiagnosed. Lichen planus overall affects 0.5-2% of the population.
Who is most commonly affected by oesophageal lichen planus?
Oesophageal involvement is most often seen in middle-aged to older adults, with a strong female predominance reported across multiple series.
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You may be at higher risk if you have a history of lichen planus affecting other parts of the body, particularly:
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Mouth (mouth ulcers/soreness, white lacy patches, gum inflammation)
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Genital lichen planus
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Skin lichen planus
However, it is important to note that sometimes, the oesophagus is the first part of the body affected by lichen planus, meaning some people develop swallowing symptoms before lichen planus is recognised elsewhere.​
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Examples of lichen planus involving the oral cavity and skin. Please note: A/Prof Sanagapalli treats lichen planus of the oesophagus only; but if you have skin or mouth signs such as these, it increases the likelihood that your oesophagus is also affected. An oral medicine specialist or dermatologist can manage lichen planus of the mouth or skin, respectively.
​Symptoms of oesophageal lichen planus
The most common symptom is dysphagia, or difficulty swallowing (e.g. food sticking in the throat or chest), particularly with solid foods but also with liquids in severe cases.
Other symptoms may include:
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Painful swallowing
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Chest pain or burning, that can mimic reflux
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Weight loss, due to inadequate oral intake
What causes oesophageal lichen planus?
Lichen planus is considered an immune-mediated or autoimmune condition. This means that the person’s immune system inappropriately targets the surface lining (mucosa) of the oesophagus and/or other affected body parts. This causes inflammation, and over time, scarring to develop. The exact trigger for the autoimmune response is often unclear.
How is oesophageal lichen planus diagnosed?
The challenge of diagnosis of this condition is that there is no single, 100% accurate diagnostic test. Therefore, diagnosis requires your specialist to have deep knowledge of the condition and a high index of suspicion, to ensure the diagnosis is not missed or made incorrectly.
Diagnosis involves a combination of:
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Careful clinical history: Key clues include difficulty swallowing plus a known history of lichen planus affecting other parts of the body, or symptoms suggestive of these conditions
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Gastroscopy (endoscopy): Clues include involvement more so in the upper part of the oesophagus (whereas the lower part is more typically involved in reflux). Typical findings include an inflamed, fragile lining, white streaks or plaques, sloughing of the lining, and thick white exudates (like pus). However, appearances can vary and be quite subtle.
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Oesophageal biopsies: Biopsy examination can provide supportive evidence but usually is not conclusive. Special stains and techniques such as immunofluorescence need to be requested by your specialist, to help exclude other disorders.
How is oesophageal lichen planus treated?
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Oesophageal dilatation
Almost always, symptoms in oesophageal lichen planus develop once the oesophagus has become narrowed from scarring (stricturing). Compared to other conditions of the oesophagus, strictures in lichen planus are often particularly severe being quite narrow and long. Therefore in A/Prof Sanagapalli’s experience, dilatation (widening) of the narrowed segments of the oesophagus is the mainstay of therapy which tends to give patients relief. Often underappreciated is the need for multiple, sometimes repeated sessions of dilatation to adequately widen the narrowed segments, and inadequate dilatation is a frequent cause of patients not getting adequate symptom improvement.
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Anti-inflammatory therapy
You may already be on some for of anti-inflammatory therapy to treat lichen planus affecting other body parts. These ‘systemic’ therapies may or may not have an effect on the oesophageal disease. Sometimes, anti-inflammatory therapy directed specifically at the oesophagus may be required. These could include accd suppressing medications (e.g., proton pump inhibitors) or swallowed topical steroids. These are similar to other steroid medications such as prednisone, but are locally acting on the oesophagus and don’t have the bad side effect protocol that systemic steroids have. A/Prof Sanagapalli is conducting research (currently enrolling patients) into a new formulation of anti-inflammatory therapy for oesophageal lichen planus. Click here to read about some preliminary results.​
Do I need ongoing monitoring or surveillance?
There are no universally accepted guidelines for surveillance intervals in oesophageal lichen planus. That said, because of the reported increased risk of squamous cell cancer of the oesophagus in patients with this condition, A/Prof Sanagapalli usually recommends that patients with the condition have a periodic endoscopy for surveillance purposes.
Is oesophageal lichen planus the same as reflux?
No. Reflux is caused by stomach acid inappropriately rising into the oesophagus, whereas lichen planus is an autoimmune disorder of the oesophagus. However, reflux is far more common, and symptoms can overlap, hence many patients with oesophageal lichen planus may be misdiagnosed as reflux.
I already had an endoscopy and lichen planus wasn’t mentioned. Could it have been missed?
Yes. The appearances can be subtle, and biopsies don’t give a conclusive answer, only supportive information – but the specialist who orders the biopsies must specifically tell the pathologist that he or she is looking for this condition, otherwise the pathologist won’t know. For this reason, if you have persistent unexplained symptoms, it is imperative that the endoscopy is performed by a specialist who has experience with the condition.
Who should I see to help manage my oesophageal lichen planus?
Because oesophageal lichen planus is uncommon and often misdiagnosed, patients with persistent dysphagia or unexplained oesophagitis may benefit from review by a gastroenterologist with a particular focus on complex inflammatory and structural disorders of the oesophagus, including careful endoscopic assessment, appropriate biopsy strategy, and management of strictures where present. Consult an expert in oesophageal diseases with clinical and research experience in oesophageal lichen planus, who can make a conclusive diagnosis and guide you through the therapeutic options. Click below or call us to make an appointment with A/Prof Santosh Sanagapalli.