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Abstract: The patient reported that white ring-shaped ocarina damage appeared on the tongue six months ago, which worsened in the past month, and he came to our hospital with a self-conscious feeling of woodiness, burning, dry mouth, occasional insect crawling itch, and burning and irritation pain when eating irritating food. No significant abnormality was seen on completion of relevant examinations, but the final diagnosis of oral lichen planus was made through the pathology of localized lesions on the tongue. The patient was given medication, which was effective after treatment, and the discomfort disappeared.
Basic information】Female, 50 years old
Type of disease] Oral lichen planus
Hospital】The Second Affiliated Hospital of Nanchang University
Date of consultation】March 2018
Treatment plan】Medication (tretinoin injection + lidocaine hydrochloride injection + thalidomide tablets + yupingfeng granules)
Treatment period】Outpatient treatment for six months, and review in January, February and June
Treatment effect】Good results, disappearance of discomfort symptoms
I. Initial interview
In March 2018, a 50-year-old female patient, Ms. Yu, came to our hospital. The patient reported: white ring-shaped damage appeared on the tongue six months ago, which has worsened in the past month, and she felt a woody, burning sensation, dry mouth, occasional itching sensation of insect crawling, and burning and irritation pain when eating irritating food. The patient was in good health and denied history of smoking, systemic diseases and drug allergy. Physical and specialist examination: The patient had general oral hygiene, multiple ring-shaped white lesions were seen on both sides of the tongue, and reticular lesions were also seen on both cheeks, with mucosal congestion, but no other significant abnormalities were seen. Based on the clinical manifestations of the patient and the histopathology taken from the tongue lesions, it was concluded that the lesions showed hyperkeratosis or incomplete keratinization of the epithelium, liquefied degeneration of the basal cells or serrated changes, and a large number of lymphocytic infiltrative bands were seen below the basement membrane, which confirmed the diagnosis of oral lichen planus.
Second, the treatment process
After detailed communication with the patient, the patient agreed to the treatment and signed the informed consent form. After communicating with the patient, the patient confided that he had been depressed for the past year due to stress, and his health was not too good, and he was more irritable. In response to the patient’s psychological stress, the patient was advised to learn to talk and communicate with his family and friends at the right time to relieve his mood. At the same time, medication was administered, including local closure with trimethoprim injection + lidocaine hydrochloride injection and oral thalidomide tablets + yupingfeng granules. The patient was also advised to adhere to long-term treatment and to visit the clinic for review at 1, 2 and 6 months.
III. Treatment effect
After the patient underwent active drug treatment, he felt relaxed and his discomfort symptoms improved, and the interval between follow-up visits gradually increased from once every half month at the beginning to 1 month and 3 months, with the interval gradually extended. After 3 months of treatment, the patient’s symptoms of wood astringency, burning sensation and dry mouth were significantly reduced, and the white ring-shaped ocarina on the tongue was gradually reduced. After adhering to the treatment for half a year, the patient’s discomfort symptoms were significantly reduced and the condition was stable into the resting phase, and the patient was satisfied with the treatment effect.
IV. Notes
We are glad that the patient’s condition keeps improving after adhering to the treatment. In daily life, patients should pay attention to oral hygiene, brush their teeth regularly, rinse their mouth before and after meals, and avoid irritating factors. Patients learn to regulate their own emotions, pay attention to remove anxiety and depression, maintain a happy mood, regular life, less late night; diet, avoid eating spicy and stimulating food, such as raw onion, ginger, garlic, etc., to help the recovery of local skin lesions.
V. Personal insight
The cause of oral lichen planus is not clear, and the high prevalence includes people with underlying diseases, people with poor nutrition and women before and after menopause, such as the patient in this case. When there are white annular lesions in the oral cavity, patients should be correctly guided to pay high attention to this disease, and after the diagnosis is determined, a complete treatment plan should be formulated to keep oral lichen planus under control through topical drug administration, and the recovery after treatment should be observed through regular review to avoid further development.