Der Lichen planus des Ösophagus – Eine unterschätzte Erkrankung

Zusammenfassung

Eine Beteiligung des Ösophagus bei der Hauterkrankung Lichen planus wurde erstmals 1982 beschrieben und fast 30 Jahre lang als eine Rarität angesehen. Untersuchungen der letzten 10 Jahre aber zeigen, dass diese Erkrankung weniger selten ist als angenommen. Es ist sogar anzunehmen, dass der ösophageale Lichen planus (Esophageal Lichen planus, ELP) häufiger ist als die Eosinophile Ösophagitis (EoE). Die Ösophagusbeteiligung betrifft meist Frauen im mittleren Alter. Das Hauptsymptom ist eine Dysphagie. Endoskopisch erkennt man in der Speiseröhre eine charakteristische Schleimhautablösung, eine Trachealisierung, und gelegentlich Hyperkeratosen und bei langem Bestehen auch Stenosen. Wegweisend ist die Histologie mit einer subepithelialen Ablösung sowie einem bandförmigen Infiltrat aus T-Lymphozyten, dem Nachweis von apoptotischen Keratinozyten (Civatte Bodies) und Dyskeratosen. Die direkte Immunfluoreszenz zeigt Fibrinogen-Ablagerungen entlang der Basalmembran. Eine etablierte Therapie gibt es bisher nicht. Die Behandlung mit topischen Steroiden ist in 2/3 der Fälle wirksam. Eine Therapie wie beim klassischen Lichen planus scheint unwirksam zu sein. Bei symptomatischen Stenosen kann eine Dilatation indiziert sein. Der ELP reiht sich in die Gruppe der „neuen“ immunologisch vermittelten Erkrankungen des Ösophagus ein.

Abstract

An involvement of the esophagus in patients with lichen planus was described for the first time in 1982. Ever since, it has been seen as a rarity. However, studies over the last 10 years have shown a higher prevalence than expected. It may even be supposed that esophageal lichen planus (ELP) is more common than eosinophilic esophagitis. ELP mostly affects middle-aged women. The principal symptom is dysphagia. Endoscopically, ELP is characterized by denudation and tearing of the mucosa, trachealization and hyperkeratosis and esophageal stenosis may occur in patients with long courses of the disease. Histologic findings including mucosal detachment, T-lymphocytic infiltrate, intraepithelial apoptosis (civatte bodies) and dyskeratosis are crucial. Direct immunofluorescence shows fibrinogen deposits along the basement membrane zone. So far, there is no well-established therapy but a treatment with topic steroids is effective in 2/3 of the patients. Common therapy of lichen planus of the skin seems to be ineffective for treatment of ELP. Symptomatic esophageal stenosis should be endoscopically dilated. ELP joins the group of „new“ immunologic diseases of the esophagus.

Schlüsselwörter

Lichen planus - Ösophagitis - Eosinophile Ösophagitis - Dysphagie - Budesonid - Autoimmunkrankheit - T-Lymphozyten

Key words

lichen planus - esophagitis - eosinophilic esophagitis - dysphagia - budesonide - autoimmune disorder - T-lymphocytes

^* Gemeinsame Erstautorschaft von Carmen Monasterio und Annegrit Decker.

Publication History

Received: 20 November 2020

Accepted: 26 January 2021

Article published online:
08 April 2021

• Literatur

• 1 Jansson-Knodell CL, Codipilly DC, Leggett CL. Making Dysphagia Easier to Swallow: A Review for the Practicing Clinician. Mayo Clin Proc 2017; 92: 965-972 DOI: 10.1016/j.mayocp.2017.03.021.
• 2 Straumann A, Spichtin HP, Bernoulli R. et al. [Idiopathic eosinophilic esophagitis: a frequently overlooked disease with typical clinical aspects and discrete endoscopic findings]. Schweiz Med Wochenschr 1994; 124: 1419-1429
• 3 Dellon ES. Eosinophilic esophagitis: diagnostic tests and criteria. Curr Opin Gastroenterol 2012; 28: 382-388 DOI: 10.1097/MOG.0b013e328352b5ef.
• 4 Dellon ES, Liacouras CA, Molina-Infante J. et al Updated International Consensus Diagnostic Criteria for Eosinophilic Esophagitis: Proceedings of the AGREE Conference. Gastroenterology 2018; 155: 1022-1033.e10 DOI: 10.1053/j.gastro.2018.07.009.
• 5 Greuter T, Safroneeva E, Bussmann C. et al Maintenance Treatment Of Eosinophilic Esophagitis With Swallowed Topical Steroids Alters Disease Course Over A 5-Year Follow-up Period In Adult Patients. Clinical Gastroenterology and Hepatology 2019; 17: 419-428.e6 DOI: 10.1016/j.cgh.2018.05.045.
• 6 Lucendo AJ, Miehlke S, Schlag C. et al Efficacy of Budesonide Orodispersible Tablets as Induction Therapy for Eosinophilic Esophagitis in a Randomized Placebo-Controlled Trial. Gastroenterology 2019; 157: 74-86.e15 DOI: 10.1053/j.gastro.2019.03.025.
• 7 Quispel R, van Boxel OS, Schipper ME. et al High prevalence of esophageal involvement in lichen planus: a study using magnification chromoendoscopy. Endoscopy 2009; 41: 187-193 DOI: 10.1055/s-0028-1119590.
• 8 Katzka DA, Smyrk TC, Bruce AJ. et al Variations in presentations of esophageal involvement in lichen planus. Clin Gastroenterol Hepatol 2010; 8: 777-782 DOI: 10.1016/j.cgh.2010.04.024.
• 9 Kern JS, Technau-Hafsi K, Schwacha H. et al. Esophageal involvement is frequent in lichen planus: study in 32 patients with suggestion of clinicopathologic diagnostic criteria and therapeutic implications. Eur J Gastroenterol Hepatol 2016; DOI: 10.1097/MEG.0000000000000732.
• 10 Podboy A, Sunjaya D, Smyrk TC. et al Oesophageal lichen planus: the efficacy of topical steroid-based therapies. Aliment Pharmacol Ther 2017; 45: 310-318 DOI: 10.1111/apt.13856.
• 11 Schauer F, Monasterio C, Technau-Hafsi K. et al Esophageal lichen planus: towards diagnosis of an underdiagnosed disease. Scandinavian Journal of Gastroenterology. 2019 Im Internet (Stand: 06.11.2019): https://www.tandfonline.com/doi/abs/10.1080/00365521.2019.1674375
• 12 Le Cleach L, Chosidow O. Clinical practice. Lichen planus. N Engl J Med 2012; 366: 723-732 DOI: 10.1056/NEJMcp1103641.
• 13 Payette MJ, Weston G, Humphrey S. et al Lichen planus and other lichenoid dermatoses: Kids are not just little people. Clinics in Dermatology 2015; 33: 631-643 DOI: 10.1016/j.clindermatol.2015.09.006.
• 14 Weston G, Payette M. Update on lichen planus and its clinical variants. International Journal of Women’s Dermatology 2015; 1: 140-149 DOI: 10.1016/j.ijwd.2015.04.001.
• 15 Gru AA, Salavaggione AL. Lichenoid and interface dermatoses. Semin Diagn Pathol 2017; 34: 237-249 DOI: 10.1053/j.semdp.2017.03.001.
• 16 Gorouhi F, Davari P, Fazel N. Cutaneous and mucosal lichen planus: a comprehensive review of clinical subtypes, risk factors, diagnosis, and prognosis. ScientificWorldJournal 2014; 2014: 742826 DOI: 10.1155/2014/742826.
• 17 Cooper SM, Wojnarowska F. Influence of treatment of erosive lichen planus of the vulva on its prognosis. Arch Dermatol 2006; 142: 289-294 DOI: 10.1001/archderm.142.3.289.
• 18 Warnakulasuriya S, Kovacevic T, Madden P. et al Factors predicting malignant transformation in oral potentially malignant disorders among patients accrued over a 10-year period in South East England. J Oral Pathol Med 2011; 40: 677-683 DOI: 10.1111/j.1600-0714.2011.01054.x.
• 19 DeAngelis LM, Cirillo N, McCullough MJ. The immunopathogenesis of oral lichen planus-Is there a role for mucosal associated invariant T cells?. J Oral Pathol Med 2019; 48: 552-559 DOI: 10.1111/jop.12898.
• 20 Blauvelt A, Chiricozzi A. The Immunologic Role of IL-17 in Psoriasis and Psoriatic Arthritis Pathogenesis. Clin Rev Allergy Immunol 2018; 55: 379-390 DOI: 10.1007/s12016-018-8702-3.
• 21 Boutet M-A, Nerviani A, Gallo Afflitto G. et al. Role of the IL-23/IL-17 Axis in Psoriasis and Psoriatic Arthritis: The Clinical Importance of Its Divergence in Skin and Joints. Int J Mol Sci 2018; 19 DOI: 10.3390/ijms19020530.
• 22 Nagao Y, Nishida N, Toyo-Oka L. et al Genome-Wide Association Study Identifies Risk Variants for Lichen Planus in Patients With Hepatitis C Virus Infection. Clin Gastroenterol Hepatol 2017; 15: 937-944.e5 DOI: 10.1016/j.cgh.2016.12.029.
• 23 Georgescu SR, Tampa M, Mitran MI. et al Potential pathogenic mechanisms involved in the association between lichen planus and hepatitis C virus infection. Experimental and Therapeutic Medicine 2019; 17: 1045-1051 DOI: 10.3892/etm.2018.6987.
• 24 Lefer LG. Lichen planus of the esophagus. Am J Dermatopathol 1982; 4: 267-269 DOI: 10.1097/00000372-198206000-00017.
• 25 Al-Shihabi BM, Jackson JM. Dysphagia due to pharyngeal and oesophageal lichen planus. J Laryngol Otol 1982; 96: 567-571 DOI: 10.1017/s0022215100092835.
• 26 Keate RF, Williams JW, Connolly SM. Lichen planus esophagitis: report of three patients treated with oral tacrolimus or intraesophageal corticosteroid injections or both. Dis Esophagus 2003; 16: 47-53
• 27 Reissmann A, Hahn EG, Faller G. et al Sole treatment of lichen planus-associated esophageal stenosis with injection of corticosteroids. Gastrointest Endosc 2006; 63: 168-169 DOI: 10.1016/j.gie.2005.07.045.
• 28 Bombeccari GP, Pallotti F, Guzzi G. et al. Oral-esophageal lichen planus associated with oral squamous cell carcinoma. Indian J Dermatol Venereol Leprol 2008; 74: 509-511
• 29 Hou JK, Qureshi W. Swallowed fluticasone for the treatment of esophageal lichen planus. Gastrointest Endosc 2011; 74: 708-709 DOI: 10.1016/j.gie.2010.09.032.
• 30 Miehlke S, Reinhold B, Schröder S. [Successful treatment of Lichen planus esophagitis with topical budesonide]. Z Gastroenterol 2012; 50: 1104-1107 DOI: 10.1055/s-0032-1312979.
• 31 Ynson ML, Forouhar F, Vaziri H. Case report and review of esophageal lichen planus treated with fluticasone. World J Gastroenterol 2013; 19: 1652-1656 DOI: 10.3748/wjg.v19.i10.1652.
• 32 Nielsen JA, Law RM, Fiman KH. et al Esophageal lichen planus: a case report and review of the literature. World J Gastroenterol 2013; 19: 2278-2281 DOI: 10.3748/wjg.v19.i14.2278.
• 33 Kolios AGA, Marques Maggio E, Gubler C. et al Oral, esophageal and cutaneous lichen ruber planus controlled with alitretinoin: case report and review of the literature. Dermatology (Basel) 2013; 226: 302-310 DOI: 10.1159/000349980.
• 34 Goñi Esarte S, Arín Letamendía A, Vila Costas JJ. et al [Rituximab as rescue therapy in refractory esophageal lichen planus]. Gastroenterol Hepatol 2013; 36: 264-267 DOI: 10.1016/j.gastrohep.2012.07.004.
• 35 Eustace K, Clowry J, Kiely C. et al The challenges of managing refractory oesphageal lichen planus. Ir J Med Sci 2015; 184: 75-76 DOI: 10.1007/s11845-014-1136-x.
• 36 Ravi K, Codipilly DC, Sunjaya D. et al Esophageal Lichen Planus Is Associated With a Significant Increase in Risk of Squamous Cell Carcinoma. Clin Gastroenterol Hepatol 2019; 17: 1902-1903.e1 DOI: 10.1016/j.cgh.2018.10.018.
• 37 Chryssostalis A, Gaudric M, Terris B. et al Esophageal lichen planus: a series of eight cases including a patient with esophageal verrucous carcinoma. A case series. Endoscopy 2008; 40: 764-768 DOI: 10.1055/s-2008-1077357.
• 38 Podboy AJ, Alexander JA, Smyrk TC. et al. Occurrence of IgG4 in Esophageal Lichen Planus. Clin Gastroenterol Hepatol 2017; DOI: 10.1016/j.cgh.2017.06.008.
• 39 Haque S, Genta RM. Lymphocytic oesophagitis: clinicopathological aspects of an emerging condition. Gut 2012; 61: 1108-1114 DOI: 10.1136/gutjnl-2011-301014.
• 40 Rubio CA, Ichiya T, Schmidt PT. Lymphocytic oesophagitis, eosinophilic oesophagitis and compound lymphocytic-eosinophilic oesophagitis I: histological and immunohistochemical findings. J Clin Pathol 2017; 70: 208-216 DOI: 10.1136/jclinpath-2016-203782.
• 41 Rouphael C, Gordon IO, Thota PN. Lymphocytic esophagitis: Still an enigma a decade later. World J Gastroenterol 2017; 23: 949-956 DOI: 10.3748/wjg.v23.i6.949.
• 42 Albert DM, Ally MR, Moawad FJ. The sloughing esophagus: a report of five cases. Am J Gastroenterol 2013; 108: 1816-1817 DOI: 10.1038/ajg.2013.230.
• 43 Hart PA, Romano RC, Moreira RK. et al Esophagitis Dissecans Superficialis: Clinical, Endoscopic, and Histologic Features. Dig Dis Sci 2015; 60: 2049-2057 DOI: 10.1007/s10620-015-3590-3.
• 44 Hokama A, Yamamoto Y-I, Taira K. et al Esophagitis dissecans superficialis and autoimmune bullous dermatoses: A review. World J Gastrointest Endosc 2010; 2: 252-256 DOI: 10.4253/wjge.v2.i7.252.
• 45 Carmack SW, Vemulapalli R, Spechler SJ. et al Esophagitis dissecans superficialis („sloughing esophagitis“): a clinicopathologic study of 12 cases. Am J Surg Pathol 2009; 33: 1789-1794 DOI: 10.1097/PAS.0b013e3181b7ce21.
• 46 Akhondi H. Sloughing esophagitis: a not so common entity. Int J Biomed Sci 2014; 10: 282-286
• 47 Chan LS. Mucous membrane pemphigoid. Clin Dermatol 2001; 19: 703-711
• 48 Kuten-Shorrer M, Menon RS, Lerman MA. Mucocutaneous Diseases. Dent Clin North Am 2020; 64: 139-162 DOI: 10.1016/j.cden.2019.08.009.
• 49 Ma C, Limketkai BN, Montgomery EA. Recently highlighted non-neoplastic pathologic entities of the upper GI tract and their clinical significance. Gastrointest Endosc 2014; 80: 960-969 DOI: 10.1016/j.gie.2014.09.009.
• 50 Dickens CM, Heseltine D, Walton S. et al The oesophagus in lichen planus: an endoscopic study. BMJ 1990; 300: 84 DOI: 10.1136/bmj.300.6717.84.
• 51 Straumann A, Katzka DA. Diagnosis and Treatment of Eosinophilic Esophagitis. Gastroenterology 2018; 154: 346-359 DOI: 10.1053/j.gastro.2017.05.066.
• 52 Fox LP, Lightdale CJ, Grossman ME. Lichen planus of the esophagus: what dermatologists need to know. J Am Acad Dermatol 2011; 65: 175-183 DOI: 10.1016/j.jaad.2010.03.029.
• 53 Ioannides D, Vakirlis E, Kemeny L. et al European S1 guidelines on the management of lichen planus: a cooperation of the European Dermatology Forum with the European Academy of Dermatology and Venereology. J Eur Acad Dermatol Venereol 2020; 34: 1403-1414 DOI: 10.1111/jdv.16464.
• 54 Katzka DA, Smyrk TC, Bruce AJ. et al Variations in presentations of esophageal involvement in lichen planus. Clin Gastroenterol Hepatol 2010; 8: 777-782 DOI: 10.1016/j.cgh.2010.04.024.
• 55 Harewood GC, Murray JA, Cameron AJ. Esophageal lichen planus: the Mayo Clinic experience. Dis Esophagus 1999; 12: 309-311
• 56 Linton MS, Zhao L, Gui X. et al Lichen planus is an uncommon cause of nonspecific proximal esophageal inflammation. Gut Liver 2013; 7: 401-405 DOI: 10.5009/gnl.2013.7.4.401.