Esophageal Lichen Planus

Esophageal lichen planus, also known as esophageal lichen planus disease (ELP), was first described in 1982 (Al-Shihabi et al. 1982).

Lichen planus infestation of the esophagus. Esophageal lichen planus was initially interpreted as a rare manifestation of lichen planus of the skin (LP). Versch. However, various studies have shown esophageal involvement in up to 50 % of patients with cutaneous or oral LP (Quispel R et al. 2009). ELP is not necessarily associated with oral involvement, but can also occur with purely cutaneous LP. However, oral lichen planus is observed in most patients with severe ELP (Fox LP et al. 2011). Furthermore, an esophageal manifestation is associated with the occurrence of other mucosal involvement, such as genital LP, with above-average frequency.

Determining the actual prevalence of ELP remains a statistical challenge. Reliable figures would require endoscopic screening of a large group of patients with lichen planus (LP), regardless of the localization of the disease or clinical symptoms. Assuming that around 10 % of all LP patients have esophageal involvement, the estimated prevalence in the general population could reach 0.1 %, which would exceed the known prevalence of eosinophilic esophagitis (0.04-0.05 % in Western countries) (Straumann A et al. 2018). A higher association of ELP can be assumed for oral LP.

Pathophysiology (analogous to skin): CD8⁺-T-cell-mediated cytotoxicity; attack on basal keratinocytes of the squamous epithelium; interface dermatitis here: Interface mucositis. Molecularly dominated by an IFN-γ-dominated immune response ( CXCL9/10 axis) with an epithelial apoptosis process.

The average age at first presentation is 60 years; 70-80% of patients are female (Kreysel W et al. 2025).

Typical symptoms are: dysphagia, odynophagia, retrosternal burning with the feeling that the food is "stuck". Weight loss may occur consecutively. Many patients are initially misinterpreted as:reflux disease, candida esophagitis or eosinophilic esophagitis. The clinical spectrum ranges from asymptomatic courses to severe symptoms. In principle, oesophageal lichen planus can be considered a precancerous condition. Patients with symptomatic dysphagia should therefore be examined endoscopically.

In patients with oral lichen planus (ELP) and dysphagia, esophageal LP should always be considered. Many cases are only recognized years later as they may be asymptomatic!

Endoscopic findings: Proximal involvement of the esophagus is characteristic. There are whitish plaques or a whitish reticular pattern. There is clear mucosal fragility ("mucosal sloughing"). The lack of distal reflux erosions of the esophageal reflux is also typical.

Band-shaped lymphocytic infiltrate, hyperkeratosis/parakeratosis of the epithelium, basal cell damage, apoptotic keratinocytes (Civatte bodies), basal fibrin deposits.

Drug-induced lichenoid esophagitis: anamnesis, histology

GvHD (anamnesis and clinic, skin changes "scleroderma-like")

Pemphigus vulgaris (detection of pemphigus antibodies)

Eosinophilic esophagitis (clinical and histology are diagnostic)

Local (first line) - Oral topical steroids:

• e.g. budesonide viscous
• Fluticasone spray

Systemic (for severe courses)

• Systemic corticosteroids
• azathioprine
• mycophenolate
• cyclosporine
• Retinoids (individual cases)

Newly discussed: The use of JAK inhibitors: Several case reports and case series have described the safety and efficacy of upadacitinib, tofacitinib, baricitinib and ruxolitinib (1 article) in the treatment of LP variants (Motamed-Sanaye A et al. 2022).

The successful use of phosphodiesterase-4 inhibitors such as apremilasthas also been reported (Tekin B et al. 2024).

Regular endoscopic checks are strongly recommended!

There is a relevant oncological risk of increased formation of squamous cell carcinoma of the esophagus (analogous to oral lichen planus; the data are limited).

In patients with oral lichen planus (ELP) and dysphagia, esophageal LP should always be considered. Many cases are only recognized years later.

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