Oral Lichen Planus (OLP) was first recorded by Anderasen and Pindborg (1). OLP is a chronic inflammatory disease that affects the mucosa in the oral cavity. Currently, there are 6 types of oral lichen planus clinically: reticular (the most common type, showing fine white line at the lesion), atrophic, papular, bullous, plaque, and erosive types (2). OLP affects women by a 1.4:1 ratio over men (2). The origin and pathogenesis of OLP have been a hot topic for decades; however, it remains mysteriously unexplained. Therefore, the treatment methods vary. Many authors point out that there is a strong correlation between psychological factors (stress, anxiety, and depression) and the development of OLP (3, 4). Furthermore, scholars have argued that counseling sessions and stress management should be part of the OLP management protocol (2).

A 32-year-old female patient was referred to the Department of Clinical Psychology due to severe affective symptoms in the past 4 months. Eight years ago, the onset of her symptoms was triggered by the extreme unpleasantness between the patient and her mother. Heteroanamnestic revealed that the patient grew up in a divorced family, and then lived with her mother afterwards. Her mother often abused her verbally. The fierce quarrels reached peak 4 months ago. After that, the patient began to develop affective and psychosomatic symptoms, including poor sleep quality, anhedonia, loss of appetite, stomach pain, and fatigue. Therefore, she was hospitalized for further observation due to depression. The medical history of the patient revealed that she was diagnosed with OLP 5 months before this referral. As stated by the patient, 9 months ago, she suffered from discomfort when chewing and speaking. Although the patient thought that it was an aphthous ulcer, she did not receive any treatment. However, after a few months, as the tension between the patient and her mother deteriorated, the patient began to develop more severe symptoms, including a burning sensation in the oral cavity and increased sensitivity to spicy and hot foods. She then reported that she went to Beijing Stomatological Hospital and was diagnosed with OLP (5). The stomatologist prescribed budesonide, vitamin B2, cetylpyridnium chloride, and advised her to visit the Department of Clinical Psychology. The patient reported that she did not feel better after taking traditional OLP drugs, and later forget the detailed information about OLP drugs, such as what the type and dose of Budesonide was, and whether other corticosteroid drugs such as triamcinolone was used. In addition, the patient denied having parafunctional habits such as bruxism or clenching.

The patient neither smoked nor drank. She was single and had no history of pregnancy. Her family members disclosed no mental illness. During the mental status examination, the patient looked tired and pale, and she could not help crying. The patient had a flat affect when answering questions. She spoke slowly. Cognitive function was very good. The patient's behaviors and facial expressions showed low mood and moderate anxiety. In the subsequent psychological assessments, including the Minnesota Multiphasic Personality Inventory-2 (MMPI-2), Self-Rating Depression Scale (SDS) and Self-Rating Anxiety Scale (SAS), the results revealed that she had relatively high levels of depression and anxiety (scores: SDS = 65, SAS = 70).

Her vital signs were stable, and no abnormal physical or neurological signs were detected at admission. The patient's blood biochemical results were all within the normal range, including blood cell analysis, C-reactive protein (CRP), hepatic function, renal function, infection markers, the quantitation of HBV markers, thyroid function, prolactin, sex hormone, alexin (C4), antinuclear antibodies, antinuclear extract antibody spectrum determination, folic acid, vitamin B12, trace elements, procalcitonin (PCT), and cortisol. However, alexin (C3: 0.8 g/L, normal: 0.9–1.8 g/L) was decreased. Also, the test results of urine sediment quantification, urine analysis, fecal analysis, and occult blood analysis were all within the normal range. Electroencephalogram (EEG) and electrocardiograph (ECG) showed no abnormalities; however, during the first brain MRI examination, the pituitary signal was found to be uneven. Seven days later, the second examination of pituitary dynamic enhanced MRI scan showed no abnormality. During the hospitalization, the patient went to consult the stomatology doctor of our hospital to reconfirm diagnose of OLP. The result of consultation was that there were white plaques on bilateral buccal mucosa, upper and lower mandibular vestibular sulcus mucosa, and a small amount of reticulation in the buccal sulcus, which could not be removed. There were ulcers and erosions in the white metamorphic areas of the vestibular sulcus, superficial, and tenderness. Taken together, the diagnosis was reconfirmed to be oral lichen planus. Because the patient's oral ulcers were severe, the stomatologist did not recommend pathological and immunological examinations, nor recommend changing medications. According to the International Classification of Diseases (ICD-10), she was diagnosed with a depressive episode when she came to our hospital. The initial treatment was Venlafaxine (75 mg, every morning), Lorazepam (0.5 mg, every morning and every night), Shugan jieyu capsules (0.72 g, every morning and every night), together with the drugs for the treatment of OLP. But the drugs for the treatment of OLP was discontinued a week after admission.

Consultation meetings were arranged once a week, mainly using psychoanalytic methods to resolve inner conflicts with her mother, and cognitive behavior therapy (CBT) to adjust her emotions toward certain people and events. The effect was remarkable. A week and a half later, the patient reported that her mood was elevated and she barely cried. Moreover, the abdominal pain disappeared, and the burning and tightening sensation in the oral cavity gradually subsided.

After 1 month of follow-up, the patient's symptoms were significantly reduced, indicating that the psychotherapy had a good effect, and she continued to adhere to psychological counseling twice a week. The drug dose was gradually reduced. Lorazepam and Shugan jieyu capsules were discontinued, and only venlafaxine (75 mg, every morning) was taken. No obvious drug and psychological side effects were observed. The assessment results revealed relatively low levels of depression and anxiety (scores: SDS = 50, SAS = 48) (Table 1).

Although the etiology of OLP is unknown, we witnessed a tremendous recovery in patient's oral and mental conditions treated with psychotropic medications and multiple psychotherapeutic methods. Based on previous clinical studies, it is generally believed that mental stress is one of the possible risk factors for the development of OLP (6). A previous study showed that in postmenopausal women, stress could lead to anxiety and depression, which are common reasons of lichen planus (7). A study showed that 48% of the 274 OLP patients had mental problems, and anxiety, depression and stress existed in 45% of these OLP patients with mental problems (3). In other studies, OLP group had much higher anxiety, depression, and stress (8, 9). Taken together, these studies indicate that stress, anxiety, and depression may be the cause of OLP, and also the cause of OLP relapses.

Many authors believe that among patients with mental disorders, such as depression or psychological stress, changes in the immune system may also lead to OLP (6). In this case, due to insignificant effect after taking conventional drugs for OLP, we suspected that intense emotions may play a key role in her prolonging symptoms. Therefore, we added psychotropic drugs to strengthen the treatment, together with psychotherapies. In the end, the patient's condition responded well. The oral, psychosomatic, and mental symptoms gradually alleviated. In short, although we cannot verify the causal relationship between psychological factors and OLP, we had successfully used psychiatric drugs and psychotherapies to control OLP, when traditional treatments first failed.

There were two main limitations. First, the clinical description of the OLP lesions, including the type of lesions, location, and severity of the lesion according to an accepted criterion such as “Thongprasom,” and the severity of pain and burning symptoms according to the VAS should be thoroughly compared before, after treatment and after follow-up. It should be best to have images of the OLP lesions for each stage. However, unfortunately, we did not record the specific conditions of the OPL lesions in detail due to the limit of the subjective conditions in our clinical practice. Second, in this treatment, we did not evaluate the efficacy of drugs and psychological counseling separately, but only evaluated the overall efficacy of the treatment after a period of time. We will evaluate the effects of drugs and psychological therapy separately for other clinical patients.

In this case report, we witnessed and emphasized the importance of using a combination of psychiatric drugs and psychotherapies to treat emotion-related OLP. We believe that psychotropic drugs can enhance the patient's brain function, and psychotherapies can relieve stress, enabling patients to have a better quality of life in the future. From the current clinical evidence, the correlation between psychological factors and OLP is strong; however, the causality has not been verified. In the future, we need to better understand the etiology of OLP, so more research needs to be done so that OLP patients can efficiently obtain the most direct guidance and effective treatment.

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.

Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.

XS, XW, and SS treated this patient and wrote the paper. CW contributed to the manuscript preparation. XS and XZ critically reviewed the diagnostic results and proofreading the manuscript. All authors read and approved the final version of the manuscript.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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