Efficacy of Intralesional Injection of Autologous Platelet Rich Plasma Versus Intralesional Injection of Corticosteroids on Pain Relief and Ulcers Healing in Patients With Erosive Oral Lichen Planus; Randomized Clinical Trial
Phase: PHASE2
Conditions: Erosive Oral Lichen Planus
Sponsor: Cairo University

Efficacy of intralesional injection of autologous 
platelet rich plasma versus intralesional injection of 
corticosteroids on pain relief and ulcers healing in 
patients with erosive oral lichen planus 
Randomized clinical trial 
 
 
 
 
Protocol submitted to oral medicine, diagnosis and periodontology 
department at faculty of dentistry, Cairo University for partial 
fulfillment of Doctoral degree in Dentistry 
(ORAL MEDICINE AND DIAGNOSIS) 
 
 
By: 
Abdelhameed Hamid Mohammad Hijazi 
M.Sc. of Oral Medicine 
Faculty of Dentistry 
Cairo University 
 
 
 
 
 
 
(2017) 

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Supervisors: 
 
 
 
 
 
 
Prof. Dr. Soheir Gaafar 
Professor of Oral Medicine, Diagnosis and Periodontology  
Faculty of Dentistry 
Cairo University 
 
 
 
Dr. Wessam Abdel Moneim 
Associate Professor of Oral Medicine, Diagnosis and Periodontology 
Faculty of Dentistry 
Cairo University 
 
 
 
 
 
 
 
 
 

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Administrative information 
 
- Title:  
Efficacy of intralesional injection of autologous platelet rich plasma 
versus intralesional injection of corticosteroids on pain relief and ulcers 
healing in patients with erosive oral lichen planus 
Randomized clinical trial 
 
- Trial registration:  
It is intended to be registered in Clinicaltrials.gov registry database. 
 
- Funding  
Self-funded. 
 
- Roles and responsibilities  
 
1. Dr. Abdelhameed Hamid Mohammad Hijazi; (H.A.) PhD Candidate at Oral 
medicine, diagnosis and periodontology department, Cairo University. 
The primary investigator in the study (performing the interventions of the trial 
and collecting data) 
 
2. Prof. Soheir Gaafar; (G.S.) Professor of Oral Medicine at Oral medicine, 
diagnosis and periodontology department, Cairo University.  
The main supervisor of the study. 
 
3. Dr. Wessam Abdel-Moneim; (A.W.) Associate professor of Oral Medicine at 
Oral medicine, diagnosis and periodontology department, Cairo University.  
Outcomes assessor and Co-supervisor of the study. 
 
 
 
 

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Introduction 
 
- Background and rationale  
Lichen planus (LP) is a chronic mucocutaneous inflammatory disease 
that frequently affects the oral mucosa, it tends to affect mostly middle-
aged white female patients. Oral lichen planus (OLP) occurs more 
frequently than the cutaneous form, it is estimated to affect 0.5% to 2% of 
the general population and tends to be more persistent and more resistant 
to treatment (Edwards & Kelsch, 2002).  Oral lichen planus (OLP) can 
present clinically in six different patterns: papular, reticular, plaque, 
atrophic, erosive and bullous, each have specific characteristics and can be 
found isolated or associated together. The most prevalent type of those is 
the reticular type, which is characterized by the presence of Wickham 
striae, which are typically symmetric, bilateral, asymptomatic, and mainly 
found in the buccal mucosa. The erosive form, despite being less frequent, 
presents greater clinical significance as the lesions are usually 
symptomatic, ranging from a minimal discomfort to episodes of severe 
pain (Payeras et al., 2013). 
 
In OLP disease, antigen-specific and non-specific mechanisms both 
may be involved in its pathogenesis. Antigen specific mechanisms in OLP 
include antigen presentation by basal keratinocytes and antigen specific 
keratinocyte killing by CD8+ cytotoxic T-cells. Non-specific mechanisms 
include mast cell degranulation and matrix metalloproteinase (MMP) 
activation in OLP lesions. These mechanisms may act simultaneously to 
cause T-cell accumulation in the superficial lamina propria, basement 
membrane disruption, intra-epithelial T-cell migration, and keratinocyte 
apoptosis in OLP. It has been hypothesized that OLP chronicity may be 
due, to some extent, to deficient antigen-specific TGF-β1-mediated 
immunosuppression (Sugerman et al., 2002). 
 
Topical corticosteroids have been considered the first-choice agent for 
the treatment of OLP, corticosteroids are especially helpful in the 
management of OLP because of their anti-inflammatory effect and anti-
immunologic properties, but their prolonged use should be avoided 
because of the associated adverse effects (Lodi et al., 2005). Lee et al., 
2013 compared topical approach with intralesional injection in patients 

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with oral lichen planus and reported that intralesional injection with 
triamcinolone acetonide has significantly less side effects compared to 
topical application. 
 
Platelet Rich Plasma (PRP) is a plasma concentrate of the patient’s 
blood that predominantly contains platelets. In the PRP, apart from a high 
concentration of platelets, an increase in all coagulation factors may be 
recorded. Activated platelets release different growth factors that 
contribute to cell migration, proliferation, differentiation, angiogenesis, 
removal of tissue debris and regeneration of the appropriate type of tissues 
(Pietrzak & Eppley, 2005).  
 
Growth factors, to be specific cytokines and chemokines, include 
platelet derived growth factors (PDGF-aa, -bb and -ab isomeric), 
transforming growth factors-β (TGF-β, - β 1 and - β 2 isomeric), 
interleukin-1, platelet-derived angiogenesis factor, vascular endothelial 
growth factor, epidermal growth factor, epithelial cell growth factor, 
platelet-derived endothelial growth factor, insulin-like growth factor, 
fibronectin and others are found in large numbers in alpha granules within 
platelets (Dionyssiou et al., 2013) 
 
PRP injections because of the high concentration of growth factors has 
been used in various conditions, including chronic ulcers and wound 
healing (Martinez-Zapata et al., 2012). Bolanča et al., 2016 reported 
beneficial effect of using PRP injections in lichen planopillaris resistant to 
intralesional corticosteroids. Another study conducted by El-Komy et al., 
2015 reported significant clinical improvement of resistant oral erosions in 
patients with pemphigus vulgaris after intralesional injection of PRP.  
 
PRP injections had been used widely in the treatment of tendons injuries 
and in orthopedic surgeries to promote healing and regeneration (Dohan 
et al., 2014). Also in temporomandibular joint disorders, PRP injections 
has proven to be effective in pain relief, reduction of the inflammatory 
signs in the joint (Hegab et al., 2015). For oral surgeries and periodontal 
defect repairs also PRP had shown a significant role in tissue regeneration 
(Mostafa et al., 2013; Hou et al., 2016). 
   

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Recently Loré et al., 2016 compared in a pilot study the effect of PRP 
gel with cyclosporine mouth wash and retinoic acid lotion in different OLP 
phenotypes; namely erosive, reticular and plaque type OLP, respectively. 
They concluded that treatment of OLP should take into consideration the 
phenotype of the disease, as PRP has a high concentration of growth factors 
it is advised to be used in erosive type, which proved to be effective when 
applied once weekly. 
 
Rationale:   
We are conducting this clinical trial to provide a safe alternative 
treatment for patients suffering from resistant erosive oral lichen planus; 
which had proved a promising regenerative potentials. 
 
- Hypotheses: 
The intralesional injections of platelet rich plasma has the same effect 
of intralesional injections of triamcinolone acetonide regarding pain relief 
and ulcers healing in patients with erosive oral lichen planus  
- Trial design allocation ratio,   
The study is a randomized clinical trial with parallel groups, exploratory 
framework. 
 
 
 
 
 
 
 
 
 
 

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Methods Participants, interventions, and outcomes 
 
- Study setting:  
Oral medicine clinic at the Faculty of dentistry, Cairo University.  
 
- Eligibility criteria: 
  
1. Inclusion criteria:  
Patients presenting with a clinical picture that assumes the diagnosis of 
erosive oral lichen planus (bilateral, more or less symmetrical erosive 
lesions with lacelike network of slightly raised gray white lesions (reticular 
pattern), and a histological findings that confirms the diagnosis 
(liquefaction degeneration of the basal cell layer with irregular–saw teeth 
like rete pegs.  
 
2. Exclusion criteria: 
 Systemic 
disorders 
such 
as 
hematological 
diseases, 
severe 
cardiovascular diseases, treatment with any drugs that could cause 
Lichenoid reaction.  
 Pregnancy or active breastfeeding   
 Patients who had lesion/lesions with dysplasia   
 Patients who received topical treatment for Oral Lichen planus in the 
last 2 weeks (Lee et al., 2013) or systemic treatment for OLP in the past 
3 months.  
 Platelet count < 150,000/mm3; Hgb < 11 g/dl.  
 Immunosuppressed patients 
 Patients receiving therapy with anticoagulants and use of non-steroidal 
anti-inflammatory drugs in the 5 days before taking the blood sample. 
 
 
 
 
 

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- Interventions: 
PRP will be prepared in the dental clinic from autologous blood 
collected in the same visit according to Mostafa et al., 2013:  
a. Twelve ml of peripheral blood will be drawn from the patient's 
antecubital fossa into a sterile citrated graduated plastic falcon tube 
(tube 1) containing anticoagulant sodium citrate (best support for 
platelet viability) in the ratio of 1/10 (12 ml blood and 1.2 ml sodium 
citrate), under complete sterile conditions.  
b. Tube 1 will be shaken gently to enhance complete mixing of the 
blood with anticoagulant and left to sediment for 45 min. to obtain 
the best yield.  
c. First Spin: Tube 1 will be centrifuged using a standard common 
bench centrifuge (model 800 D, maximum speed 4000 rpm) at speed 
of 500 rpm for 10 min, resulting into separation of the whole blood 
into 3 layers: a bottom layer comprised of red blood cell (RBCs), 
middle layer comprised of platelets and white blood cells (buffy 
coat), high concentration of platelets was found in the boundary 
layer between the two regions and top plasma layer of platelet poor 
plasma.  
d. The upper plasma layer and middle layer (1-2ml of the top part of 
the RBC layer known as buffy coat), will be aspirated using a sterile 
Pasteur pipette and transferred to another plastic tube (tube 2), while 
the RBCs fraction will be discarded. 
e. Second spin: Tube 2 will be centrifuged first at speed of 1000 rpm 
for 5 min, then elevated to 1500 rpm for 5 min more, as a result, the 
platelets will be concentrated at the bottom, leaving the PPP at the 
upper portion of the tube.  
f. The upper layer PPP will be aspirated with Pasteur pipette and 
separated in tube 3, leaving nearly 1.5ml of serum with concentrated 
platelets (PRP) at the bottom in tube 2.   
g. The sedimented PRP (1.5 ml) will be kept at room temperature 
and will be mixed well before use. 
In control group, triamcinolone acetonide 40 mg (Kenacort A vial; 
*SmithKline Beecham Co.; Egypt*) will be used for intralesional injections 
once every week for 4 weeks (Lee et al., 2013).  

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The injections in both groups will be applied after a field block with 
Mepevicaine 3% *Alexandria Co.; Egypt* anesthetic without vasoconstrictor. 
An amount of 0.5 ml of each treatment will be injected per 1cm2 of 
ulcerated mucosa using a 25 gauge needle. 
 
- Outcomes  
Primary outcome:  
Pain self-assessed by the patient using an 11-point (0-10) 
numerical rating scale, in which (0 = no pain) and (10 = worst 
possible pain) (Seymour, 1982) 
Secondary outcome:  
1- Clinical picture assessed by Thongprasom sign scoring 
(Thongprasom et al., 1992), the measures will be recorded using 
a calibrated squared grid as following: 
Score 0= no lesions, normal mucosa  
Score 1= mild white striae, no erythematous area  
Score 2= White striae with atrophic area less than 1 cm2  
Score 3= White striae with atrophic area more than 1 cm2  
Score 4= White striae with erosive area less than 1 cm2  
Score 5= White striae with erosive area more than 1 cm2 
2- Remission time according to Conrotto et al., 2006: the measures 
will be recorded using a binary scale [(Yes/Stable or No/Not 
stable): Yes indicates signs score more than 1; No indicates signs 
score equals 1 or less.  
 
Baseline characteristics will be recorded by the primary investigator 
(H.A.) and the assessor (Dr. A.W.) who will be blinded, before the 
treatment using the previous scale and score, the difference in each 
outcome will be recorded at the beginning of each visit during the trial and 
in the follow up visits. 
 

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- Participant timeline  
A biopsy of the lesion will be performed for histopathologic 
examination for the confirmation of the diagnosis of the new undiagnosed 
patients, after that recruited patients will be assigned to one of the groups 
(intervention or control), after that, all participants in intervention group 
should provide a recent complete blood picture to confirm that their 
platelets count is over 150000, then a pre-treatment records will be 
obtained for the lesions. 
After that each week the same treatment protocol for each group will be 
followed for consecutive 4 weeks, in total 4 injections will be injected for 
each participant. 
After the last injection the patients will be followed up for 1 week to 
obtain the endpoint measures.  
All participants will be followed up by the primary investigator H.A. 
every 2 weeks for 3 months from the last visit to report flare episodes of 
the disease. 
 
- Sample size:  
The aim of this study is to compare between the intralesional injection 
of autologous platelet rich plasma in treatment of patients with erosive type 
of oral lichen planus and the intralesional injection of corticosteroids. 
Based on previous studies by Xia et al., 2006, a total sample size of 8 (4 
in each group) will have 90% power to detect a difference in the VAS 
means between the 2 groups of 49.69 (the difference between the 
intervention group with mean of 8.33 and the control group with mean of 
49.69) assuming that the intervention group standard deviation is 10.11 and 
the control group standard deviation is 12.85 using t-test with a 0.05 two-
sided significance level. The number is increased to a total sample size of 
10 to allow for the use of non-parametric test. To allow for 25% losses, the 
sample was further increased to 14 (7 participants in each group).  
Sample size estimation was performed by nQuery statistical package. 
 

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- Recruitment:  
Patient's database from the department of oral medicine, diagnosis and 
periodontology will be filtered by their condition, eligible subjects will be 
contacted to ask for follow up visit. 
Those who agree to be enrolled in the trial will be asked to sign an 
informed consent, then all participants will be allocated randomly to either 
study groups according to the computer generated sequence. 
 
Allocation 
- Sequence generation  
Simple randomization using computer based sequence generation 
software will be used after patients' consent of enrollment. 
- Allocation opaque, sealed Concealment are assigned mechanism   
No concealment will be used in this trial, as the interventions can't be 
blinded from the patients or the investigator (too obvious to know). 
- Implementation  
The primary investigator H.A. will be responsible for the sequence 
generation, allocation and enrollment of the participants. 
- Blinding 
Dr. A.W. the assessor of outcomes will be blinded; as she will NOT be 
involved of any step during patients' allocation or during treatment 
delivery.  
No circumstances will make unblinding permissible. 
- Data collection, management, and analysis Data collection methods  
Data collected by the primary investigator H.A. and the assessor Dr. 
A.W. will be revised by the main supervisor (Dr. G.S.) at the end of the trial 
after 4 weeks and after 3 months of follow up. 
Patients will be followed up every 2 weeks for 3 months after the last 
visit to check flare ups of the disease, the primary investigator H.A. and the 
assessor Dr. A.W. are responsible for the follow up records. 
  

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- Data management   
Each participant will have 2 separate files, one with the primary 
investigator H.A. and the second will be with the assessor Dr. A.W., rather 
than the original administrative file in the department of oral medicine. 
- Statistical methods:  
Data will be analyzed using IBM SPSS advanced statistics (Statistical 
Package for Social Sciences), version 23 (SPSS Inc., Chicago, IL). 
Numerical data will be described as mean and standard deviation or median 
and range, as appropriate. Comparisons between the intervention and the 
control group will be performed using the Mann-Whitney test. A p-value 
less than or equal to 0.05 will be considered statistically significant. All 
tests will be two tailed. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Monitoring 
- Data monitoring  
Data will be recorded directly by the assessor (Dr. A.W.) and another 
reading will be recorded by the primary investigator (H.A.) of the trial, then 
reviewed by the main supervisor (Dr. G.S.) with no involvement of other 
parties in the process. 
- Harms  
Short term use of the treatments of the trail will cause minimum side 
effects according to published evidence, although exaggerated pain or 
flare up of the disease after starting the treatment will be recorded and the 
adverse effect will be dealt as following: 
1- Pain after injections: the patient will be informed about the 
probability of exaggerated pain feeling at the injection site, 
analgesics will be prescribed for each patient Ibuprofen 400 mg 
(Brufen tablet; *Kahira Pharmaceuticals & Chemical industries Co.; 
Cairo*), when needed 
2- Flare ups of the lesions; the patient will be shifted to another 
treatment modality 
 
- Auditing  
The auditing will be held every week for 4 weeks from the start of the 
trial and every 2 weeks for 3 months of treatment free follow up period, 
pain reporting using numerical rating scale and photos of the lesions will 
be obtained in every visit by the assessor Dr. A.W. and the primary 
investigator H.A. separately to allow inter-assessor reliability check. 
 
 
 
 
 
 

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Ethics and dissemination     
- Research ethics approval  
It is planned to get the approval from committee of Ethics at the Faculty 
of Dentistry, Cairo University 
 
- Protocol amendments  
Amendments will be revised and approved by the supervisors Dr. G.S. 
and Dr. A.W., then registered to Clinicaltrials.gov registry database. 
- Consent or assent  
The primary investigator H.A. will obtain informed consents from each 
participant. 
- Confidentiality  
The patients file will only be reviewed by the primary investigator 
(H.A.), assessor (Dr. A.W.)- Who will be blinded of the treatment received- 
and the supervisors (Dr. G.S. and Dr. A.W.) of the trial. 
- Declaration of interests  
We declare no financial interests for the overall trial. 
- Access to data  
Primary investigator (H.A.) and supervisors (Dr. G.S. and Dr A.W.) of 
the study only will have access to patient records (except the assessor Dr. 
A.W. who will be blinded) and health information. 
- Ancillary and post-trial care  
The primary investigator H.A. will be held responsible for the post trial 
care and compensation for any harm from the trail participation. 
- Dissemination policy  
Study results will be published in an international journal and contacts 
of the primary investigator H.A. as well the supervisors Dr. G.S. and Dr. 
A.W. will be listed in the published paper. 
 

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