Diagnosing and Treating Lichen Planus of the Oesophagus

Lichen planus of the oesophagus is a rare inflammatory disorder that can cause painful or difficult swallowing, food sticking, chest discomfort and, over time, narrowing of the oesophageal passage. It may occur alongside oral, skin, scalp or genital lichen planus, although oesophageal disease can occasionally be the first recognised sign.

Diagnosis is often delayed because symptoms resemble reflux or eosinophilic oesophagitis. A gastroenterologist usually needs to combine the medical history, endoscopic appearance and carefully collected biopsies. Treatment aims to control inflammation, maintain swallowing function and prevent recurrent strictures.

Recognising the symptoms and risk pattern

Progressive dysphagia is the most important symptom. People may first notice difficulty with dry bread, meat or tablets, then develop trouble with softer foods and liquids. Odynophagia, or painful swallowing, can occur when the lining is fragile or ulcerated.

A history of oral lichen planus, recurrent mouth soreness, white lacy patches, skin lesions or nail changes increases suspicion. In Australia, a general practitioner in Brisbane, Perth or regional New South Wales may initially manage presumed reflux, so persistent symptoms should prompt review rather than repeated over-the-counter treatment.

Confirming the diagnosis with endoscopy

Upper endoscopy, or gastroscopy, allows direct assessment of the oesophagus and biopsies from abnormal and apparently normal areas. Findings may include a rough or friable lining, white slough, longitudinal lesions, mucosal tearing and strictures, often affecting the upper or middle oesophagus.

Several biopsies are important because the disease can be patchy. The pathologist may identify basal cell degeneration, apoptotic keratinocytes, a band-like lymphocytic infiltrate and separation near the epithelial basement membrane. Direct immunofluorescence can sometimes help distinguish lichen planus from mucous membrane pemphigoid and related blistering disorders.

Excluding look-alike conditions

The diagnostic process should consider eosinophilic oesophagitis, gastro-oesophageal reflux, pill injury, candida infection, caustic injury, graft-versus-host disease and autoimmune blistering disorders. Oesophageal cancer must also be excluded when there is weight loss, bleeding, progressive obstruction or an irregular mass.

A dermatology or oral medicine assessment may reveal useful signs outside the oesophagus. In complex cases, review by a gastroenterologist, dermatologist and experienced gastrointestinal pathologist is valuable. Australian patients may be treated through a public hospital multidisciplinary clinic or a private specialist pathway, depending on location, urgency and insurance arrangements.

Relieving narrowing and protecting swallowing

A stricture can make even anti-inflammatory treatment ineffective because medication may not reach the active lining below the narrowed segment. Endoscopic dilation can restore the passage, but it must be performed cautiously because inflamed oesophageal tissue is delicate and may tear.

Dilation may need to be repeated, particularly when inflammation remains active. A soft diet, careful chewing and nutritional support can help while treatment takes effect. A dietitian can assist with maintaining protein and calorie intake, especially for people waiting for a procedure through a busy public endoscopy service.

Medical treatment for active inflammation

There is no universally accepted treatment protocol because oesophageal lichen planus is uncommon and evidence mainly comes from case series and specialist experience. Swallowed topical corticosteroids are often considered, using preparations designed to contact the oesophageal lining rather than being inhaled into the lungs.

Systemic corticosteroids may be used for severe, extensive or rapidly progressive disease. Steroid-sparing medicines such as mycophenolate, azathioprine or other immune-modifying therapy may be considered when symptoms recur or prolonged steroid exposure is unsafe. Proton pump inhibitors can help coexisting reflux, but acid suppression alone does not treat the underlying immune inflammation.

Monitoring response and possible complications

Follow-up assesses swallowing, nutrition, medication effects and recurrent narrowing. Repeat endoscopy may be required when symptoms persist, return after dilation or change in character. New bleeding, vomiting, food impaction or inability to swallow liquids requires urgent medical assessment.

Long-standing inflammatory injury may increase concern about squamous cell cancer, although the size of that risk remains uncertain. Surveillance should therefore be individualised rather than based on a rigid timetable. Patients should report a new persistent symptom instead of assuming it is another flare.

Practical care points for Australian patients

Access can vary between metropolitan and regional areas. A patient in Hobart, Darwin or rural Queensland may need referral to a tertiary gastroenterology service for advanced endoscopy, specialist pathology or coordinated immune treatment. Medicare may cover medically necessary public-hospital care, while private consultations, pathology and medicines can involve out-of-pocket costs.

Useful information to bring to appointments includes:

• A list of swallowing symptoms and foods that cause difficulty
• Photographs or records of oral, skin or nail lesions
• Previous gastroscopy and pathology reports
• A complete list of medicines, supplements and allergies

During treatment, practical safety measures include:

• Eating slowly and choosing soft, moist foods during flares
• Taking tablets only with adequate water unless advised otherwise
• Reporting oral thrush, fever or steroid-related side effects
• Keeping scheduled reviews after dilation or medication changes

Coordinating long-term specialist care

Because this condition crosses gastroenterology, dermatology, oral medicine and pathology, coordinated care is often more effective than isolated appointments. The International Society for Diseases of the Esophagus promotes education and research in this field, and specialist congress resources can help clinicians keep up with rare oesophageal disorders.

The immediate goal is safe swallowing; the longer-term goal is durable control of mucosal inflammation and prevention of repeated strictures. In practical terms, persistent or progressive swallowing difficulty should lead to specialist assessment, properly targeted biopsies and a treatment plan that combines inflammation control with careful nutritional and endoscopic support.