|Year : 2019 | Volume
| Issue : 1 | Page : 68-71
Association of lichen planus with dyslipidemia: A comparative, cross-sectional study
Neema Azeez, Neelakandhan Asokan
Department of Dermatology and Venereology, Government Medical College, Thrissur, Kerala, India
|Date of Web Publication||14-Feb-2019|
Department of Dermatology and Venereology, Government Medical College, Thrissur, Kerala
Source of Support: None, Conflict of Interest: None
Context: Lichen planus (LP) is an idiopathic T-cell-mediated inflammatory disorder. Chronic inflammation may result in derangement of lipid metabolism. Some studies have shown that prevalence of dyslipidemia is more among patients with LP, whereas other studies have not supported this hypothesis. Aims: The aim of this study is to find out if there is any association between LP and dyslipidemia. Settings and Design: The study was conducted at the dermatology outpatient department of a tertiary care hospital; this was a comparative, cross-sectional study. Subjects and Methods: Forty-seven patients with LP aged 20 years or more attending the dermatology department of a tertiary care hospital were recruited for the study. Comparison group consisted of 47 age- and sex-matched patients with skin infections of <1 month duration. Fasting lipid profile of all participants was estimated. Proportion of patients with dyslipidemia in both groups was compared using Chi-square test. Student's t-test for equality of means and Levene's test for equality of variances were used to compare the lipid profile values in both groups. Statistical Analysis Used: Chi-square test, Student's t-test for equality of means, and Levene's test for equality of variances. Results: Dyslipidemia was observed among 30 (63.8%) patients in the LP group and among 23 (48.9%) patients in the comparison group (P = 0.145; odds ratio = 1.84; 95% confidence interval = 0.81–4.2). There was no significant difference in mean serum cholesterol (P = 0.096), triglycerides (P = 0.318), high-density lipoprotein (HDL) (P = 0.901), and low-density lipoprotein (LDL) (P = 0.077) between the two groups. Levene's test of equality of variances showed that differences in the variability between patients in the LP and in the comparison group were significant for serum cholesterol values (P = 0.036), but not for serum triglycerides (P = 0.821), HDL (P = 0.343), and LDL (P = 0.841). Conclusions: Although the prevalence of dyslipidemia was more among patients with LP, it was not significant at 5% level.
Keywords: Dyslipidemia, inflammation, lichen planus
|How to cite this article:|
Azeez N, Asokan N. Association of lichen planus with dyslipidemia: A comparative, cross-sectional study. Clin Dermatol Rev 2019;3:68-71
| Introduction|| |
Lichen planus (LP) is a common chronic inflammatory disorder of the skin, mucous membranes, nails, and hairs, characterized by violaceous, pruritic, polygonal flat-topped papules usually distributed bilaterally, symmetrically more on the extremities.
It is known that psoriasis, another common inflammatory skin disease, mediated by T-cells is associated with an increased risk of cardiovascular risk factors, including hypertension, diabetes mellitus, obesity, metabolic syndrome, and dyslipidemia. Several cytokines (tumor necrosis factor [TNF] alpha, interleukin-2 [IL-2], and IL-6) have been implicated as the cause of increased lipid levels in patients with psoriasis. LP also is considered as a T-cell-mediated inflammatory disorder. TNF-alpha and interferon-gamma have been shown to be present in high concentrations in the skin lesions of LP. Hence, it is possible that LP also is associated with dyslipidemia. Some studies have reported an association between LP and dyslipidemia,,,,, whereas some studies have not. Hence, we thought that it would be worthwhile to find out if there is any association between LP and dyslipidemia among patients aged 20 years or more attending the dermatology and venereology outpatient department of our tertiary care teaching hospital.
| Subjects and Methods|| |
Forty-seven consecutively attending patients aged 20 years or more with LP attending the dermatology outpatient department of a tertiary care hospital from March 2014 to June 2015 constituted the case group. Inclusion criterion was a clinical diagnosis of LP, made by a faculty member with postgraduate degree in dermatology and venereology. Patients with lichenoid drug eruption, those receiving systemic corticosteroids or other immunosuppressant drugs, patients receiving topical corticosteroids or calcineurin inhibitors for a period exceeding 1 month at the time of enrollment, and those who were not willing to participate in the study were excluded. Comparison group consisted of 47 age- and sex-matched patients with skin infections of <1 month duration. The study was approved by the Institutional Ethics Committee.
The sample size was calculated for an expected prevalence of dyslipidemia of 50% in the study group and 30% in the comparison group based on some previous studies.,, All study participants were clinically evaluated and the data were recorded in a pro forma. Laboratory investigations included hemogram, fasting blood sugar, and fasting lipid profile (total serum cholesterol, triglycerides, high-density lipoprotein-cholesterol [HDL-c], low-density lipoprotein-cholesterol [LDL-c], and very LDL-c). Lipid profile was estimated in the samples of venous blood drawn between 8 am to 9 am after 12 h of fasting. Patients were asked to stick to their habitual diet for at least 1 week preceding the laboratory evaluation.
Dyslipidemia was defined as per the National Control Education Programme-Adult Treatment Panel III guidelines. According to this, a patient was considered to have dyslipidemia if any one of the following was present:
- Serum total cholesterol >200 mg/dl
- Serum triglycerides >150 mg/dl
- Serum LDL-c >130 mg/dl
- Serum HDL-c <40 mg/dl for males and <50 mg/dl for females
- If the patient was already receiving the treatment for dyslipidemia.
Statistical analysis was done using SPSS software version 17, SPSS Inc., 233, South Wacker Drive, 11th floor, (Chicago, IL, USA). Mean and standard deviation were used to analyze descriptive data. The proportion of patients with dyslipidemia was compared between case group and comparison group, using Chi-square test. Odds ratio (OR) with confidence interval (CI) was also calculated. P < 0.05 was considered statistically significant. Levene's test for equality of variances and Student's t-test were used to measure the variability between the lipid values of the study group and the comparison group.
| Results|| |
Age of the patients ranged from 16 to 80 years (mean = 49.15 + 17.3). The most frequent (23.4%) age group of the patients was 60–69 years, followed by 50–59 years (19.1%) [Table 1]. There were 27 females and 20 males in the study group. Duration of LP ranged from 2 weeks to 7 years (mean = 13.3 + 17.4 weeks). Family history of LP was provided by only 2 (4.2%) patients, who were siblings – the brother having hypertrophic LP and the sister having macular LP.
Papules and plaques of classical LP were the most common morphological type of skin lesions, seen in 25 (53.2%) patients with skin lesions, followed by mucosal LP in 10 (21.2%) patients and hypertrophic lesions in 8 (17%) patients. LP pigmentosus and follicular LP were seen in one (2.1%) patient each [Table 2]. Two (4.2%) patients had vesiculobullous LP. Koebner phenomenon was seen in 22 (46.8%) patients. Palms were involved in 9 (19.1%) patients whereas soles were involved in 8 (17.1%) patients. Oral mucosa was involved in 24 (51%) patients and genital mucosa in 6 (12.7%) patients. Nail changes were seen in 13 (27.7%) of patients and consisted of longitudinal ridges, longitudinal pigmented lines, hyperpigmentation of proximal nail folds, pterygium formation, and thinning of nail plates.
Thirty (63.8%) patients had dyslipidemia compared to 23 (48.9%) in the comparison group (χ2 = 2.12, P = 0.145; OR = 1.841; 95% CI = 0.807–4.203). A comparison of mean values of serum cholesterol, serum triglycerides, HDL, and LDL and their standard deviations in the LP group and the comparison group is given in [Table 3]. The t-test for equality of means revealed that there was no significant difference in mean serum cholesterol (P = 0.096), triglycerides (P = 0.318), HDL (P = 0.901), and LDL (P = 0.077) values between patients with LP and those in the comparison group. Levene's test of equality of variances showed that differences in the variability of serum cholesterol between patients with LP and those in the comparison group was significant (P = 0.036), but it was not significant in the case of serum triglycerides (P = 0.821), HDL (P = 0.343), and LDL (P = 0.841).
|Table 3: Mean values of serum cholesterol triglycerides, high-density lipoprotein, and low-density lipoprotein among patients with lichen planus and the comparison group|
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Nineteen out of 30 patients (63.3%) with LP of < 1 year duration had dyslipidemia compared to 11 out of 17 patients (64.7%) with disease of more than 1 year duration (χ2 = 0.009, P = 0.47; OR = 1.06; 95% CI = 0.30–3.89). Eight out of 11 patients (72.7%) with generalized disease had dyslipidemia compared to 22 out of 36 patients (61.1%) with localized disease (χ2 = 0.49; P = 0.26; OR = 1.68; 95% CI = 0.39–8.99).
| Discussion|| |
In our study, a greater proportion of patients with LP were found to have dyslipidemia than an age- and sex-matched comparison group although the result was not statistically significant at 5% level. Dreiher et al. reported that the prevalence of dyslipidemia among Israeli patients with LP was 42.5%. In a comparative study by Arias-Santiago et al., the prevalence of dyslipidemia among patients with LP was 61% compared to 33% for controls. López-Jornet et al. observed 58% prevalence of dyslipidemia among patients with oral LP. They also noted a significantly higher triglyceride levels in patients with atrophic-erosive types than reticular types. In a recent study by Panchal et al., the prevalence of dyslipidemia among patients with LP was 30%, compared to 6% for controls.
Gupta and Gupta noted a significantly low plasma total cholesterol, HDL-c, and triglycerides in patients with oral LP and other oral precancerous lesions when compared to controls. They concluded that lower levels of plasma cholesterol and other lipid constituents seen among patients with LP might be due to their increased utilization by cells. In our study too, we found an increased prevalence of dyslipidemia among patients with LP although it was not statistically significant. One reason of this discrepancy would have been that the study may not have been powered enough to pick up less marked differences than was assumed during the sample size calculation. A comparison of key findings of our study with previous studies is given in [Table 4].
LP is a T-cell-mediated inflammatory disorder. Inflammation produces disturbances of lipid metabolism such as increase in triglycerides or decrease in HDL-c. Lipid disturbances linked to chronic inflammation lead to increased cardiovascular risk associated with dyslipidemia. Serum level of superoxide dismutase is increased whereas that of catalase is decreased in patients with LP. Aly et al. (2010) demonstrated higher levels of malondialdehyde in patients with LP. All the above factors may contribute to the development of dyslipidemia among patients with LP.
An important strength of our study is the comparative design which helped us to make inferences on association of dyslipidemia with LP. A possible limitation of this study is a relatively small sample size. We arrived at the sample size based on reported prevalence of LP in some of the previous studies. Although we found out that prevalence of dyslipidemia was more among patients with LP, our study was probably not powered enough to establish it at 5% significance level. A larger sample size would have helped us to establish such an association. Another limitation is the possible effect of confounding factors such as obesity, hypertension, and diabetes mellitus and socioeconomic status of the patients which were not explored in the study and therefore not considered during analysis. Yet another limitation is that the cross-sectional design precluded any inferences about the temporal association between LP with dyslipidemia. The findings do not preclude the possibility that some patients might have had dyslipidemia before the onset of LP.
| Conclusion|| |
We found dyslipidemia to be more frequent among patients with LP than in a comparison group consisting of acute skin infections although the result was not statistically significant at 5% level. More studies with larger sample size might help to establish the possible association between LP and dyslipidemia. If such an association is established, it would be worthwhile to screen all patients with LP for dyslipidemia and advise them about prevention and treatment of dyslipidemia. Information about preventable and treatable cardiovascular risk factors among patients with LP would lead to better treatment outcome of these patients.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Daoud MS, Pittelkow MR. Lichen planus. In: Wolff K, Goldsmith L, Katz S, Gilchrest B, Paller AS, Leffell D, editors. Fitzpatrick's Dermatology in General Medicine. 8th
ed. New York: McGraw-Hill; 2011. p. 296-312.
Rocha-Pereira P, Santos-Silva A, Rebelo I, Figueiredo A, Quintanilha A, Teixeira F, et al.
Dislipidemia and oxidative stress in mild and in severe psoriasis as a risk for cardiovascular disease. Clin Chim Acta 2001;303:33-9.
Arias-Santiago S, Buendía-Eisman A, Aneiros-Fernández J, Girón-Prieto MS, Gutiérrez-Salmerón MT, Mellado VG, et al.
Cardiovascular risk factors in patients with lichen planus. Am J Med 2011;124:543-8.
Pietrzak A, Lecewicz-Toruń B. Activity of serum lipase [EC 184.108.40.206] and the diversity of serum lipid profile in psoriasis. Med Sci Monit 2002;8:CR9-13.
Dreiher J, Shapiro J, Cohen AD. Lichen planus and dyslipidaemia: A case-control study. Br J Dermatol 2009;161:626-9.
López-Jornet P, Camacho-Alonso F, Rodríguez-Martínes MA. Alterations in serum lipid profile patterns in oral lichen planus: A cross-sectional study. Am J Clin Dermatol 2012;13:399-404.
Arias-Santiago S, Buendía-Eisman A, Aneiros-Fernández J, Girón-Prieto MS, Gutiérrez-Salmerón MT, García-Mellado V, et al.
Lipid levels in patients with lichen planus: A case-control study. J Eur Acad Dermatol Venereol 2011;25:1398-401.
Lai YC, Yew YW, Schwartz RA. Lichen planus and dyslipidemia: A systematic review and meta-analysis of observational studies. Int J Dermatol 2016;55:e295-304.
Kuntoji V, Kudligi C, Bhagwat PV, Manasa DR, Sharma A, Andanappanavar V, et al
. Dyslipidemia and metabolic syndrome in patients with lichen planus: A case-control study. J Pak Assoc Dermatol 2016;26:290-7.
Gupta S, Gupta S. Alterations in serum lipid profile patterns in oral cancer and oral precancerous lesions and conditions – A clinical study. Indian J Dent 2011;2:1-7.
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the national cholesterol education program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult treatment panel III). JAMA 2001;285:2486-97.
Panchal FH, Ray S, Munshi RP, Bhalerao SS, Nayak CS. Alterations in lipid metabolism and antioxidant status in lichen planus. Indian J Dermatol 2015;60:439-44.
] [Full text]
Grattagliano I, Palmieri VO, Portincasa P, Moschetta A, Palasciano G. Oxidative stress-induced risk factors associated with the metabolic syndrome: A unifying hypothesis. J Nutr Biochem 2008;19:491-504.
Aly DG, Shahin RS. Oxidative stress in lichen planus. Acta Dermatovenerol Alp Pannonica Adriat 010;19:3-11.
[Table 1], [Table 2], [Table 3], [Table 4]