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Study of Association Between Lichen Planus and Hepatitis C Virus Infection” Was Done by Me at Government Stanley Medical College and Hospital During “STUDY OF ASSOCIATION BETWEEN LICHEN PLANUS AND HEPATITIS C VIRUS INFECTION” This dissertation is submitted to THE TAMILNADU DR.M.G.R.MEDICAL UNIVERSITY in partial fulfillment of university rules and regulations for award of the degree of M.D BRANCH XX DERMATOLOGY, VENEREOLOGY AND LEPROSY STANLEY MEDICAL COLLEGE CHENNAI – 600 001 APRIL 2015 DECLARATION BY THE CANDIDATE I solemnly declare that the study titled “Study of association between Lichen planus and Hepatitis C virus infection” was done by me at Government Stanley Medical College and Hospital during 2012-2015 under the guidance and supervision of my HOD, Prof. Dr. V. Anandan. The dissertation is submitted to THE TAMILNADU DR. M.G.R.MEDICAL UNIVERSITY towards the partial fulfillment of requirement for the award of M.D. Degree (Branch XX) in DERMATOLOGY, VENEREOLOGY & LEPROSY. Place: Date: DR. NISHANT GUPTA CERTIFICATE BY THE GUIDE Certified that this dissertation entitled “STUDY OF ASSOCIATION BETWEEN LICHEN PLANUS AND HEPATITIS C VIRUS INFECTION” is a bonafide work done under my guidance by Dr. NISHANT GUPTA, Post-Graduate student (MD) of the Department of Dermatology, Venereology and Leprosy, Govt. Stanley Medical College, Chennai – 600 001, during the academic year 2012 – 2015. Dr. A. Ramesh, M.D, D.D. Professor Place: Department of Dermatology, Date: Govt. Stanley Medical College, Chennai- 600 001 CERTIFICATE BY THE INSTITUTION Certified that this dissertation entitled “STUDY OF ASSOCIATION BETWEEN LICHEN PLANUS AND HEPATITIS C VIRUS INFECTION” is a bonafide work done by Dr. NISHANT GUPTA, Post-Graduate student of the Department of Dermatology, Venereology and Leprosy, Govt. Stanley Medical College, Chennai – 600 001, during the academic year 2012 – 2015, in partial fulfillment of university rules and regulations for the award of MD Degree (Branch XX) Dermatology, Venereology and Leprosy. Dr. V. Anandan, M.D. Dr. AL. Meenakshi Sundaram, M.D. Head of the Department Dean Department of Dermatology Govt. Stanley Medical College, Govt. Stanley Medical College Chennai – 600001 Chennai-600 001 ACKNOWLEDGEMENTS Gratitude is least articulate of the emotions, especially when it is deep. I find myself at loss of words to express my thankfulness to Almighty God, whose blessings and power accompanied me throughout the study. Also, I feel a crisis of expression while taking the opportunity to thank my greatest asset, Parents, who are behind whatever success I have achieved till now. They have always stood by me with much needed love and strength. As a sense of triumph is very much justified at this stage of completion of this dissertation, even more is the sense of gratitude and thankfulness to Dr.AL.MEENAKSHI SUNDARAM, M.D, D.A, Dean, GOVT. STANLEY MEDICAL COLLEGE & HOSPITAL for bestowing on me the privilege of presenting this study and for enabling me to avail the institutional facilities. I am deeply indebted and thankful to Dr. V. ANANDAN, M.D, Professor and Head of Department of Dermatology and Dr. A. RAMESH, M.D, D.D, Additional Professor of Dermatology, for their valuable guidance and encouragement. Without their help, it would not have been possible to complete this study. I duly acknowledge the invaluable role played by Dr. P. ELANGOVAN, M.D, Professor and Head of Department of Venereology and Dr. S. THILAGAVATHY, M.D, D.V, Professor of Venereology, through their constant support and motivation. Words will not suffice the gratitude I owe to my beloved co-guide Dr.K.P.SARADHA, M.D, Senior Assistant Professor, Department of Dermatology, for her guidance and endless patience in moulding of the study. I am sincerely grateful to Dr. A.R. VENKATESWARAN, Professor and Head of Department of Medical Gastroenterology, for his cooperation and valuable advice. I would like to extend my thanks to all the Assistant Professors, namely Dr.K.Rajkumar, Dr. Sowmiya, Dr. Senthil Kumar, Dr. Mohana Sundari, Dr. Jayanthi, Dr. Vanathi, Dr. Mani Surya Kumar, Dr. B.K. Aarthi, Dr. Amutha, Dr. Kayalvizhi, Dr. Chithra and Dr. Ranjini, for their enthusiasm and painstaking efforts to materialize this study. I am inclined to express my gratitude to Late Dr. R. SHANTHARAMAN, M.D, D.D, Ex- Senior Assistant Professor, Department of Dermatology, for his valuable suggestions and constant inspiration. May his soul rest in peace. The friendliness and helping hand of my dear colleagues Dr. Sridhar, Dr.Sudhakar and Dr. Shubhra, is indeed unforgettable, who have helped me at every step. I whole-heatedly thank Dr. Azimudin, post-graduate, Department of Medical Gastroenterology for his constant help and favour. Last but not least, I would like to thank my patients for their consent and cooperation in the study, and also all the paramedical staff, for their support. CONTENTS S. NO. SECTION PAGE 1. INTRODUCTION 1 2. AIMS AND OBJECTIVES 5 3. REVIEW OF LITERATURE 7 4. MATERIALS AND METHODS 54 5. OBSERVATION AND RESULTS 77 6. DISCUSSION 97 7. CONCLUSION 104 8. BIBLIOGRAPHY 9. ANNEXURES 10. MASTER CHART ABSTRACT INTRODUCTION: Lichen planus is an immunologically mediated skin and mucous membrane disease, which can affect oral mucosa, the skin, genitalia, hair follicles, nails, esophagus, urinary tract, nasal mucosa, larynx and even the eyes. Lichen planus has been found in patients with Hepatitis C virus related liver disease, with variable frequency in several studies till date. However an association between HCV infection and lichen planus is uncertain because prevalence of HCV infection in patients with lichen planus varies considerably from one geographic area to another. If there is a true association, lichen planus in certain populations may be used as a sign of HCV infection in asymptomatic patients, leading to early diagnosis and treatment, and a better prognosis of infected patients. AIM AND OBJECTIVE: To study the association between Lichen planus and Hepatitis C infection in this geographical region. MATERIALS AND METHODS: PLACE: GOVT. STANLEY MEDICAL COLLEGE, CHENNAI TYPE: Prospective, Observational TIME: July 2013 to June 2014 SAMPLE SIZE: 100 lichen planus patients, 100 controls RESULTS AND CONCLUSION: The present study shows no association between lichen planus and hepatitis C infection. Based on this result, it can be concluded that anti-HCV antibody testing is not necessarily required in lichen planus patients having no risk factors for HCV infection in this geographic region. KEY WORDS: Lichen Planus, Hepatitis C virus INTRODUCTION Lichen planus is a chronic inflammatory disease of skin and mucosa, which exhibits distinct morphology and histopathology. It can affect skin, genitalia, hair follicles, nails, oral mucosa, nasal mucosa, esophagus, larynx and eyes.1 Out of enormous number of associations reported, Hepatitis C virus (HCV) infection is one of them. Lichen planus was first described by Hebra, but later named by Erasmus Wilson in 1869. The word Lichen comes from Greek word ‘leichen’, which means tree moss.1 It refers to a unique group of flower- less vegetation. And the word Planus (Latin- ‘planus’) means flat. Lichen planus is a self-limiting condition which commonly affects middle-aged adults. It involves skin, mucous membranes, hair and nails. In skin, the hallmark of lichen planus is its clinical manifestation as itchy, violaceous, flat-topped, glistening, polygonal papules and plaques, most commonly occurring over flexor aspect of extremities, especially wrist. Nail changes include ridging, thinning and sub-ungual hyperkeratosis. Scalp involvement leads to scarring alopecia. Variants of lichen planus include hypertrophic, atrophic, actinic, follicular, bullous, annular, linear and lichen planus pigmentosus.1 Oral lichen planus has low tendency for spontaneous regression as compared to cutaneous type. Clinically, oral lichen planus can be of reticular, bullous, plaque, erosive or atrophic types. Many factors are reported as far as the etiology of lichen planus is concerned. Hepatitis C virus infection is one of them. The association between lichen planus and Hepatitis C infection was first reported in 1991.3,12 Since then, many studies have supported this view and have suggested the importance of liver monitoring in patients of muco- cutaneous lichen planus. As HCV infection is usually indolent4, patients may present only in late stages of the disease with serious complications like cirrhosis and chronic liver disease. So, if association between lichen planus and HCV infection is found to be true, screening of patients with lichen planus may help in early diagnosis, treatment as well as decreased transmission of HCV infection in asymptomatic individuals. But on the contrary, if the same is not a true association, screening of lichen planus patients may result in unnecessary use of medical resources, along with financial and mental trauma to those being tested. The study will help in further supporting this fact and hence moving a step closer to frame the guidelines regarding HCV screening in lichen planus patients. Diagnosis of lichen planus is mostly clinical, but can be confirmed by histopathology in doubtful cases. Treatment options include corticosteroids, retinoids, immunosuppressive agents and other newer agents. AIMS AND OBJECTIVES 1. To study the association between lichen planus and Hepatitis C virus infection in this particular geographical region. 2. To study various clinical presentations of lichen planus. REVIEW OF LITERATURE HISTORICAL ASPECTS The name ‘lichen planus’ was given by Erasmus Wilson in 1869. The term ‘lichen’ was applied because of its clinical presentation
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