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Clin Case Rep
Clin Case Rep
10.1002/(ISSN)2050-0904
CCR3
Clinical Case Reports
2050-0904
John Wiley and Sons Inc. Hoboken

10.1002/ccr3.9431
CCR39431
CCR3-2024-04-1072.R2
Dermatology
Case Report
Case Report
Concurrent and prolonged embedded earring at the earlobe as a possible factor of erosive lichen planus
Wichyanrat
Wichyanrat Sutthinun https://orcid.org/0009-0000-8727-7528
1 s.wichyanrat@gmail.com

1 Division of Dermatology, Department of Medicine Ramathibodi Hospital, Mahidol University Bangkok Thailand
* Correspondence
Sutthinun Wichyanrat, Division of Dermatology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
Email: s.wichyanrat@gmail.com

09 9 2024
9 2024
12 9 10.1002/ccr3.v12.9 e943124 7 2024
08 5 2024
28 8 2024
© 2024 The Author(s). Clinical Case Reports published by John Wiley & Sons Ltd.
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

Key Clinical Message

Embedded earrings in adults have been reported to be a possible cause of erosive oral lichen planus.

Abstract

Erosive lichen planus is rare and its cause cannot be determined. Embedded earring in the earlobes is rare clinical presentation in adult. The concurrent nature of these two conditions has not been previously, described in the published literature. Unexpectedly, we removed the earring from the earlobe and successfully treated erosive oral lichen planus. We hypothesized that prolonged embedded earring is a possible factor that induced erosive lichen planus in this case.

ear piercing
earlobes
embedded earring
erosive oral lichen planus
foreign body
prolong embedded
source-schema-version-number2.0
cover-dateSeptember 2024
details-of-publishers-convertorConverter:WILEY_ML3GV2_TO_JATSPMC version:6.4.8 mode:remove_FC converted:09.09.2024
Wichyanrat S . Concurrent and prolonged embedded earring at the earlobe as a possible factor of erosive lichen planus. Clin Case Rep. 2024;12 :e9431. doi:10.1002/ccr3.9431
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pmc1 INTRODUCTION

We describe a case of erosive oral lichen planus with a painful nodule in the earlobe and find prolonged embedded earrings as a possible trigger factor for erosive oral lichen planus. The cause of erosive lichen planus is usually unclear, although the possible causes of oral lichen planus are immune‐related, other factors such as stress and contact allergens have been reported in the literature. The most common contact allergen is the metal in amalgam which may irritate the buccal mucosa and cause the oral lichenoid reaction. Distant metals outside the oral area might be the triggering factor for oral lichen planus, but this has never been reported in the published literature. We propose that concurrent prolonged embedded earrings as a foreign metal allergen might trigger an immune reaction in erosive oral lichen planus. This is a rare concurrent clinical presentation was successfully treated by surgically removing the prolonged embedded earring.

2 CASE HISTORY AND EXAMINATIONS

A 38‐years‐old Thai female had painful ulcer on the upper lip, lower lip, and lateral side of her tongue for 3 years. The physical examination revealed erythematous ulcerative ulcers in the upper and lower lip mucosa, and erosive gingiva, and erythematous ulcers on the lateral side of the tongue (Figure 1).

FIGURE 1 The oral mucosa of the patient had erythematous erosive patches with ulcers at the upper, lower mucosal lip and gingiva.

3 DIAGNOSIS AND INVESTIGATION

Differential diagnosis included pemphigus vulgaris, erosive lichen planus, and severe aphthous ulcer. A punch biopsy of the lesion on the lower lip was performed, and the histological results revealed lichenoid infiltration with lymphocytes, focal basal vacuolization and telangiectasia with subepidermal separation. Direct immunofluorescence demonstrated lichenoid tissue reaction with IgM, IgA, and C3 with a cytoid body and fibrinogen deposit, with a shaggy appearance at the dermo‐epidermal junction, which is correlated with pathology; therefore, we diagnosed the patient with erosive oral lichen planus. Laboratory tests for anti‐human immunodeficiency virus, anti‐hepatitis B virus, anti‐hepatitis C virus, and hepatitis B viral Antigens were negative. Complete blood count, blood urea nitrogen and creatinine, and liver function test results were within the normal ranges and anti‐desmoglein 1 and anti‐desmoglein 3 were negative, excluding pemphigus vulgaris.

The patient also complained of an inflamed nodule in her left earlobe for 1 year (Figure 2).The differential diagnosis at the first impression was an epidermal cyst or abscess. A surgery was performed to explore the left earlobe mass and intraoperative findings revealed, a retained foreign body, which was the embedded earing (Figure 3). Moreover, she could not remember when she had pierced the earrings.

FIGURE 2 The left earlobe of the patient before surgery. The arrow pointed to the inflammatory papule.

FIGURE 3 Intraoperative finding revealed an earring backing inside her left earlobe.

4 TREATMENT

The patient was diagnosed with erosive oral lichen planus 7 months previously in our department and had been treated with immunosuppressive drugs including oral prednisolone 10 mg per day and Hydroxychloroquine 200 mg per day for 3 months and switched to Methotrexate 10 mg per week and topical triamcinolone acetonide oral paste twice a day for 4 months. However, the lesion in her mouth remained painful and did not respond well to the medical treatment. Following the episode, the patient complained of a curious nodule in her left earlobe and surgical exploration revealed the foreign material as an embedded earring in her left earlobe. After removing the embedded earring, follow‐up was performed every month. The clinical history of erosive oral lichen planus showed astonishing improvement after 9 months, since the embedded earring was removed, immunosuppressive drugs had been tapered off and the wound at her left earlobe had completely healed.

5 DISCUSSION

Embedded earring is an uncommon finding in the posterior earlobe of children and has been reviewed in the pediatric literatures 1 with an incidence of 25 per 100,000 patient visits as the chief complaint among children presenting to a pediatric emergency department. Most of patients were girls with a median age of 8 years. Sixty percent of the cohort were younger than 10 years, which is different from our case report, which was interestingly found in adult with a forgotten history of ear piercing and a concurrent history of erosive oral lichen planus.

Ear piercing is a common procedure that is easily performed and often done by non‐medical personnel. Many different techniques can be employed, including needles, spring‐loaded gun, sharped studs, pins, and self‐piercing kits. Complications of ear piercing are well documented and may involve local infection, sepsis, keloid scars, sarcoidal granuloma, 2 cyst formation, bifid ear lobe deformity, and hematoma. The clinical presentation of the embedded earring, frequently involving the backs of the earring, includes ear pain, redness, and local infections.

Earrings are often embedded in earlobe (87%) and are more common in young children with thick, fleshy earlobes that have been pierced with a spring‐loaded gun. 3 , 4 Locations for embedded earring included lobule, tragus 5 and pinna, with the majority having the posterior portion of the earring embedded.

We propose the nickel, which is a common metal in cheap earring materials in Thailand, was the suspected metal in the earring in this case, since it can induce oral lichen planus and prolong contact dermatitis in the earlobe. To the best of our knowledge, prolonged embedded earring with a concurrent history of erosive oral lichen planus has never been reported in the literature. The cornerstone of treatment in oral lichen planus is removing the contact allergen, which in this case, seem to be the hidden embedded earring that might be the metal that induced the reactive lymphocyte to distant areas in the body such as the oral mucosa.

The prevalence of mucosal lichen planus is 1% among adult population. 6 Oral involvement occurs in approximately 60%–70% of patients with cutaneous lichen planus and may be the only manifestation in 20–30% of patients. Multiple types of oral lichen planus have been described, including reticular, plaque‐like, atrophic, papules, erosive or ulcerative and bullous forms. The reticulate form is the most common and is often asymptomatic. Erosive lichen planus is most common on the tongue and is extremely painful. Patch tests frequently show positive reaction to mercury, gold, and other metals in oral lichenoid reaction. Interestingly, patients with an oral lichenoid reaction, no cutaneous lichen planus, and negative patch test results often improve after amalgam removal. 7

To the best of our knowledge, a case report of a young woman presenting with earlobe keloid and found embedded foreign bodies as earring backing has been previously reported, but the coincidence of erosive oral lichen planus has not yet been reported. 8

6 CONCLUSION

We present an uncommon case of unexpectedly finding of a foreign body inside the earlobe nodules in an adult women with erosive lichen planus. The past history of ear piercing in childhood or teenager was forgotten, and the clinical history of erosive oral lichen planus improved after the embedded earring was removed. We propose that prolong embedded earring might have been the triggering factor for erosive oral lichen planus in this case. Fortunately, removing the embedded earring was the treatment of choice for the erosive oral lichen planus in this case.

AUTHOR CONTRIBUTIONS

Sutthinun Wichyanrat: Conceptualization; data curation; writing – original draft.

FUNDING INFORMATION

None declared.

CONSENT

Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.

ACKNOWLEDGMENTS

I would like to thank the dermatologist in our dermatology department at Ramathibodi Hospital, who previously treated the patient; the nurses and photographer in the minor operating room; our pathologist for the diagnosis of the biopsy and DIF interpretation; and our dermatologic resident (Dr. Sittha Sriprachyan‐anunt) who performed the excisional biopsy at the earlobe and consulted this case to the author.

DATA AVAILABILITY STATEMENT

All data produced in the case report are available upon reasonable request from the author.
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