ARTICLE
Oral involvement of psoriasis is rare. Here,
we report a case of psoriasis vulgaris with involvement of the lip in
a patient with hepatitis C virus (HCV) infection.
Case report
A 65-year-old Japanese male was referred to our department, complaining
of keratotic erythema on the extremities in 1995. He had been suffering
from type C hepatitis for several years. Physical examination showed keratotic
psoriatic plaques scattered on his elbows, the dorsa of his hands, buttocks,
and lower back. Biopsy from the dorsa of the left hand revealed typical
features of psoriasis. Results of laboratory examination on the first
visit to our department were as follows; blood urea nitrogen (BUN), 57
mg/dl (normal 7 to 18 mg/dl); serum creatinine, 8.3 mg/dl (0.7 to 1.1
mg/dl); kalium, 5.9 mEg/l (3.3 to 4.6 mEg/l); GOT, 37 U/l (10 to 34 U/l);
GPT, 66 U/l (5 to 46 U/l); gamma-GTP, 138 U/dl (8 to 61 U/dl); positive
anti-nuclear antibody (x 40, homogenous and speckled), and elevated IgG
(2,480 mg/dl, normal 1,025 to 2,070 mg/dl). PASI score was 10.6. While
he was being treated with topical vitamin D3 (tacalcitol) ointment, he
developed keratotic lesions on the lower lip. On physical examination,
the lower part of his lower lip was well-circumscribed and thickened with
silver scales on the surface (Fig.
1). Mucous membranes, palate and tongue were not affected. Histological
examination of the lip revealed acanthosis of the epidermis with parakeratosis,
and dilated capillary vessels between the elongated rete ridges with mild
cellular infiltrates (Fig.
2A, B). Direct immunofluorescence for IgG, IgM, IgA and complement
were all negative. During the course of treatment, he was not treated
with interferons for his hepatitis. Fungal infection was not found, and
standard patch testing proved negative. His psoriatic lesions persisted
despite topical application of vitamin D3 ointment.
Discussion
Oral manifestations are rare in psoriasis. A geographic tongue with
marked fissuring is frequently noted, and multiple, annular coin-sized
lesions of the buccal mucosa are also most often described. The incidence
of oral manifestations is considered to be less than 2% of psoriatic patients
[1]. Skavounou and Laskaris [2] reviewed the literature and found 68 cases.
However, involvement of only the lips is extremely rare. Clinically, oral
psoriasis other than geographic tongue is classified into two types; the
first presents as well-defined, silvery or grayish white lesions, and
the second is a diffuse erythema of the mucosa, which is found most frequently
in patients with acute exacerbations [3]. Our case is considered to belong
to the former group. A recently reported case showed that the clinical
course of oral psoriasis paralleled that of cutaneous lesions [4]. Our
case also showed that both lesions were in parallel. Histological examination
of the oral lesion demonstrated acanthosis of the epidermis with parakeratosis,
the dilated capillary vessels between elongated rete ridges, and mild
perivascular infiltrates of mononuclear cells. However, microabscess was
absent.
Several cutaneous manifestations were recently
reported in association with HCV infection. We previously reported an
association of psoriasis and HCV infection [5]. HCV may cause an imbalance
of the immune system, which may induce psoriasis. However, the severity
of psoriasis was relatively low in our patient despite strong positivity
of HCV antibody, showing that the disease severity of psoriasis does not
always correlate to the activity of type C hepatitis. It is difficult
to determine whether HCV is associated with the development of oral lesions
in this patient. HCV is frequently detected in patients with mucous lichen
planus [6], although the reason is unknown. Mucous membrane may be easily
be involved in patients with HCV infection, however, no other psoriatic
patients with HCV developed oral psoriasis in our department.
Article accepted on 19/6/01
REFERENCES
1. Dermatology in general medicine. Edited by Fitzpatrick TB,
Eisen AZ, Wolff K, Freedberg IM, Austen KF. McGraw-Hill Book Company,
second ed, p. 891-2.
2. Skavounou A, Laskaris G. Oral psoriasis: report of a case
and review of the literature. Dermatologica 1990; 180: 157-9.
3. Johns HH, Mason DK. Oral manifestations of systemic disease.
Philadelphia, PA, Saunders, 1980: 336-9.
4. Robinson CM, DiBiase AT, Leigh IM, Williams DM, Thornhill
MH. Oral psoriasis. Br J Dermatol 1996; 134: 347-9.
5. Yamamoto T, Katayama I, Nishioka K. Psoriasis and hepatitis
C virus. Acta Derm Venereol (Stockh) 1995; 75: 482-3.
6. Mignogna MD, Muzio LL, Favia G, Mignogna RE, Carbone R, Bucci
E. Oral lichen planus and HCV infection: a clinical evaluation of 236
cases. Int J Dermatol 1998; 37: 575-8.
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