Disturbance in glucose metabolism in patients of lichen planus

The aim of this study was to see the association of lichen planus (n=80) with glucose metabolism disturbance. Classic variety of lichen planus was the most common (76.3%), followed by ashy dermatosis, hypertrophic, oral, actinic and nail lichen planus. The blood glucose level 2 hours after glucose drink was abnormal in 20 cases. HbA 1 c was abnormal in 7 cases. The mean homeostasis model of assessment formulation- insulin resistance index (HOMA-IR) was 2.1 ± 1.6 and it was higher (>4.8) in 12.5% patients. Diabetes mellitus was found in 30 patients. Impaired glucose tolerance was found in 15 cases and high HOMA-IR was found in 10 cases. Total number of cases of abnormal glucose metabolism was found in 55 (68.8%) cases of lichen planus. In conclusion, patients with lichen planus  have higher risk of abnormal glucose metabolism specially diabetes mellitus.


Introduction
Lichen planus is an inflammatory keratotic dermatosis of unknown etiology, occurs in 0.5-1.9% of the population. 1-2Its classical clinical presentation is characterized by flat-topped, polygonal, papules or plaques of violet color.It affects primarily the flexure surface of the wrists, thighs, distal third of lower extremities, abdomen, genitals, nails and oral mucosa.Lichen planus is a pruritic, inflammatory disease of the skin, mucous membrane and hair follicles.It occurs throughout the world in all races.It is a common skin disease, comprising more than 0.5% of all dermatological visits.It may be familial in 1-2% of cases. 3ucose metabolism disturbance includes diabetes mellitus, impaired glucose tolerance and insulin resistance.Diabetes mellitus is a clinical syndrome characterized by hyperglycemia due to defects in insulin production, insulin action or both.Dysregulation of glucose, insulin and lipids directly related to physical signs in skin of patients with Diabetes mellitus. 4he prevalence of diabetes (20-79 years) in South-East Asia was 7.6% and predicted to be 9.1% in 2030 and in Bangladesh 6.1% in 2010 and predicted to be 7.4% in 2030. 5Impaired glucose tolerance has been referred to as prediabetes, indicating the relatively high-risk for the further development diabetes.The prevalence of impaired glucose tolerance is 4.0% in Bangladeshi population. 6Diabetes and impaired glucose tolerance can be diagnosed by using American Diabetes Association (ADA) criteria.Insulin resistance also indicates relatively high-risk for future development of diabetes.Insulin resistance can be measured by HOMA-IR (homeostasis model of assessment of insulin resistance index). 7e etiopathogenesis of lichen planus remains unknown.The current trend is to consider lichen planus as an autoimmune process, mediated by T-cells and is triggered by antigen alterations on the cell surface of the basal layer of the epithelium. 2 In addition, epidermal cells have shown abnormalities in the enzymatic activity, as well as defective carbohydrate expression, which might have a connection with hormones essential for the metabolic process.Recently, diabetes mellitus is considered to be associated with immunological changes, thus making a possible relationship between diabetes mellitus and lichen planus. 8me authors have demonstrated an incidence of diabetes mellitus between 14 and 85% in patients with lichen planus and reported abnormal glucose tolerance test results. 9-11However, some disagreed with this statement. 12,13Grinspan et al. (1966) reported a 40% prevalence of diabetes mellitus in patients with oral lichen planus. 14The variation in reported incidence of diabetes mellitus in patients with lichen planus may chiefly be explained by different methods and criteria used.In addition there is a wide variation in the frequency of glucose intolerance in these patients ranging

Abstract
The aim of this study was to see the association of lichen planus (n=80) with glucose metabolism disturbance.Classic variety of lichen planus was the most common (76.3%), followed by ashy dermatosis, hypertrophic, oral, actinic and nail lichen planus.The blood glucose level 2 hours after glucose drink was abnormal in 20 cases.HbA1c was abnormal in 7 cases.The mean homeostasis model of assessment formulation-insulin resistance index (HOMA-IR) was 2.1 ± 1.6 and it was higher (>4.8) in 12.5% patients.Diabetes mellitus was found in 30 patients.Impaired glucose tolerance was found in 15 cases and high HOMA-IR was found in 10 cases.Total number of cases of abnormal glucose metabolism was found in 55 (68.8%) cases of lichen planus.In conclusion, patients with lichen planus have higher risk of abnormal glucose metabolism specially diabetes mellitus.These wide variations in previous results motivate further investigations concerning the incidence of diabetes mellitus in people with lichen planus.The study was conducted to see the prevalence of diabetes mellitus, impaired glucose tolerance and insulin resistance in patients with lichen planus.

Materials and Methods
This Regarding types of lichen planus, 61 were classic type, 7 were ashy dermatosis, 4 were hypertrophic, 4 were oral lichen planus (Table I).
The mean fasting blood glucose was found 5.6 ± 1.0 mmol/L.Abnormal fasting blood glucose (≥7 mmol/L) was found in 18 patients (Table II).The blood glucose level 2 hours after glucose drink was abnormal level in 20 cases.High HbA1c (<6.5 percent) was detected in 7 cases.

Discussion
Although lichen planus was described more than a century ago, its etiology remains little known.Many factors have been suggested for the pathogenesis, such as immunological mechanisms, genetic characteristics, drug use and infections, particularly viral infections.Recently four mechanisms are suggested as antigen-specific cell-mediated immune response (heat shock proteins, CD4+ T helper cells, CD+ cytotoxic T-cells), nonspecific mechanism (epithelial basement membrane, mast cells, chemokines, matrix metaloproteinases), autoimmune response, humoral immunity (circulating auto antibodies to desmoglin 1 and 3). 15The autoimmune background of lichen planus could support its association with different autoimmune diseases like diabetes mellitus.But different previous studies carried out to see the association lichen planus with diabetes mellitus or glucose intolerance gave confusing results.In the current study, classic variety is the most common (76.3%), followed by ashy dermatosis, hypertrophic, oral, actinic and nail lichen planus.Panchal et al. (2015) observed that all the patients had cutaneous involvement; 40.5% presented with classic lichen planus, 13.5 oral lichen planus, 13.5% hypertrophic type, 10.8% pigmentosus type, 9.5% planopilaris type, 6.8% eruptive type, 2.7% had both oral and classic lichen planus, nail involvement and genital lichen planus type was observed in one of the patients (1.35%).In the current study it was observed that 73 (91.2%) patients were found <6.5 percent (normal) HbA1c and 7 (8.8%) was diabetic (≥6.5% HbA1c).The mean HbA1c was found 5.6 ± 0.7 percent.Nosratzehi et al. 17 and Seyhan et al. 3 showed the mean HbA1c levels in patient with oral lichen planus was 5.1 ± 1.3 and 5.9 ± 0.6% respectively, which is comparable with the present study.Here, it was observed 12.5% patient had higher HOMA-IR.Seyhan et al. 3 found the mean HOMA score of 2.3 ± 1.9, which is comparable with the present study.

Conclusion
A strong association of glucose metabolism disturbance specially diabetes mellitus with lichen planus was found.Classic variants of lichen planus are more prone to abnormal glucose metabolism.

Kamal Hossain, Mohammed Saiful Islam Bhuiyan, Abida Sultana, Mahmudur Rahman and Ommey Kulsom
Cite this ari le:)akaria ASM, Hossai MK, Bhuiya MSI, Sulta a A, Rah a M, Kulso O. Distur a e i glu ose eta olis i paie ts of li he pla us.Ba ga a dhu Sheikh Muji Med U i J.; : -.Availa le at:. a glajol.ifoA Jour al of Ba ga a dhu Sheikh Muji Medi al U i ersity, Dhaka, Ba gladeshDisturbance in glucose metabolism in patients of lichen planus A. S. M. Zakaria, Md.

Table I Distribution of lichen planus
4820hal et al. (2015)19and Nosratzehi et al. (2015)17showed the mean age was 41.2 ± 3.3 years and 44.5 ± 13.2 years respectively for lichen planus patients, which are higher than the present study.In another studyDenli et al. (2004)11found the incidence occur in early age, where they found ages ranged between 5 and 78 years mean age and SD was 42.2 ± 23.6 years.Seyhan et al. (2007)3observed that the mean age was 42.9 ± 14.1 years with range from 14 to 72 years.In persons of European countries, it appears largely after the age of 20 and peaks between the age of 40 and 70 years.3Veryfewcasesappearafterage80years.3Similarly, the mean age was higher.4,20In the current study, lichen planus was predominant in male subject.Manzoor et al. (2013)observed 50 consecutive patients of lichen planus comprising of 54.0% male and 46.0%female,18which is similar with the current study.Similarly,Naheed et al. (2002)showed male to female ratio was 3:2, which is closely resembled with the present study.4Onthe other hand, Panchal et al. (2015), 19 Nosratzehi et al. (2015), 17 Atefi et al. (2012) 20 and Brown et al. (1993) 1 found lichen planus predominant in females.
66so Nosratzehi et al.17(2015)observed the prevalence of 17.5% for impaired fasting glucose in comparison with the prevalence of 12.8% in 1993 by Bussell et al..25It seems that the relationship between diabetes and lichen planus is remarkable in Iran.Additionally,Nosratzehi et al. (2015)17investigated the relationship between impaired glucose tolerance or diabetes and the pattern of distribution of lichenoid lesions.This prevalence was found 14.6% by Christensen et al.,2630.3%byNiganetal.,9and45.6%byHalevy and Feuerman..16In this present study, 75% patients were found normal blood glucose level 2 hours after glucose drink.Unless there are concerns regarding possible hypoglycemia (blood glucose <3.9 mmol/L [70 mg/ dL]), significant hyperglycemia (fasting blood glucose of 7.0 mmol/L [126 mg/dL] or higher; 2 hour postprandial blood glucose of 11.1 mmol/L [200 mg/dL] or higher), ketoacidosis, oral infection, or infection elsewhere in the body.In another study, Bhowmik et al.6found the prevalence of diabetes mellitus 7.9% and impaired glucose tolerance 4.0% in Bangladesh community.Current study showed high prevalence of diabetes mellitus and impaired glucose tolerance 37.5 and 18% respectively in patients with lichen planus.