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Original Article

Estimation of Serum Cortisol Levels in Oral Lichen Planus Patients with

Electrochemiluminescence
Sam Jose, Jayasree Vijayalakshmi Mukundan, Joseph Johny1, Arun Tom2, Sunil Paramel Mohan2, Anjali Sreenivasan1

Departments of Oral Objectives: The objectives of this study were to compare the serum cortisol level

Abstract
Medicine and Radiology,
in oral lichen planus (OLP) patients with normal healthy individuals and to
PSM College of Dental
Science and Research,
compare the serum cortisol level in patients with erosive and nonerosive forms
Thrissur, 1Oral Medicine of OLP. Materials and Methods: A case–control study involving 60 patients within
and Radiology, 2Oral and the age group of 20–50  years was carried out. Group A  included 15 subjects
Maxillofacial Pathology, with nonerosive lichen planus, without skin involvement; Group B included
Sree Anjaneya Institute of 15 subjects with erosive lichen planus, without skin; and Group C included 30
Dental Sciences, Calicut, subjects with no apparent lesions of the oral mucosa and the skin. From the cases
Kerala, India and controls, 7mL venous blood was taken from median cubital vein two times
(between 8 and 10 am, and 4 and 6 pm) by using a 10 mL syringe from which 5 mL
was taken for estimation of serum cortisol. Results: The serum cortisol levels of
the erosive OLP patients were significantly higher than those of nonerosive OLP
patients and controls. There was no significant difference in the serum cortisol
levels between nonerosive OLP in comparison with controls.
Keywords: Cortisol, erosive, lichen planus

Introduction presumed effects on the immune system constitutes one

L   
ichen planus is a chronic inflammatory
  mucocutaneous disease that frequently involves
the oral mucosa with a prevalence of 0.04–2% of the
general population.[1,2] About half of the patients
with skin lesions have oral lesions, whereas about
25% present with oral lesions alone.[3] In 60% of
cases oral lesions precede the skin lesions. Cutaneous
lesions are typically present as small (2 mm) pruritic,
white-to-violaceous flat-topped purple papules, which
can increase in size to as much as 3 cm.
Psychological factors are strongly associated with lichen
planus, in particular high stress and anxiety levels.[4] High
anxiety level causes increase in serum cortisol level and
has been used as an indicator in the anxiety evaluation
studies.[5] In conditions such as pain and anxiety, many
metabolic and endocrine changes occur, and among
these a rise in the levels of serum cortisol is one of the
most important physiological effects. Hence, cortisol
is also known as a stress hormone and is secreted from
the adrenal gland.[6] It is suggested that anxiety with its
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of the major causative agents of oral lichen planus (OLP).
This study aimed to estimate the serum cortisol levels in
patients with OLP by electrochemiluminescence (ECL)
and compare these with normal healthy individual.
It also aimed to compare the serum cortisol levels in
patients with erosive and nonerosive forms of OLP. In
ECL, the electrochemically generated intermediates
undergo a highly exergonic reaction to produce an
electronically excited state that emits light on relaxation
to a lower-level state. This wavelength of the emitted
photon of light corresponds to the energy gap between
these two states. Photon detection is conducted with
the help of photomultiplier tubes or silicon photodiode
or gold-coated fiber-optic sensors. The importance of
ECL techniques for bio-related applications has been
well established.[7]
Address for correspondence: Dr. Sam Jose,
Department of Oral Medicine and Radiology,
PSM Dental College, Akkikavu,
Thrissur 680519, Kerala, India.
E-mail: samjose.omr@gmail.com
This is an open access journal, and articles are distributed under the terms of the
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For reprints contact: reprints@medknow.com

How to cite this article:  Jose S, Mukundan JV, Johny J, Tom A,

Mohan SP, Sreenivasan A.  Estimation of serum cortisol levels in oral
DOI: 10.4103/jpbs.JPBS_7_19
lichen planus patients with electrochemiluminescence. J Pharm Bioall Sci
2019;11:S265-8.

© 2019 Journal of Pharmacy and Bioallied Sciences  |  Published by Wolters Kluwer - Medknow S265
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Jose, et al.: Estimation of serum cortisol levels
Materials and Methods
A case–control study involving 60 patients within
the age group of 20–50 years was carried out. Group
A included 15 subjects with nonerosive lichen planus,
without skin involvement; Group B included 15
subjects with erosive lichen planus, without skin; and
Group C included 30 subjects with no apparent lesions
of the oral mucosa and the skin. From the cases and
controls, 7mL venous blood was taken from median
cubital vein two times (between 8 and 10 am, and 4 and
6 pm) by using a 10 mL syringe from which 5 mL was
taken for estimation of serum cortisol. The collected
blood was then transferred into a 5-mL clot activator
and kept for 4 minutes. Then, it was transferred to
wells of the centrifuge and centrifuged at a speed
of 2000–3000  rpm for 10 minutes. After that, the
centrifuged blood was loaded into the rack of Vitros
ECiQ, orthoclinical diagnostics automated machine,
along with calibrated cortisol reagent in Vitros cortisol
reagent pack and incubated for 15–20 minutes. The
results were generated from the automatic processor
unit of Vitros ECiQ. Data were collected and analyzed
using the SPSS software, version 22. Student’s t test and
one-way analysis of variance (ANOVA) were applied
for statistical evaluation.
Results
Demographic data analysis of Group A
In this group, the age of the subjects ranged from
20 to 50  years. Majority (9/15, 60%) of these cases
were within 41–50  years, followed by 31–40  years
(5/15, 33.33%), and least in 20–30 years (1/15, 6.6%).
Females comprised 66.66% of this group (10/15),
whereas males formed the remaining 33.4% of the
group (5/15).
Demographic data analysis of Group B
In this group, the age of the subjects ranged from 20 to
50 years. Majority of the patients (9/15, 60%) were in
the age group of 41–50 years, followed by 31–40 years
age group (5/15, 33.33%) and the least (1/15, 6.6%)
belonged to 21–30 years age group. Females comprised
66.66% of this group (10/15) whereas male comprised
the remaining 33.33% of the group (5/15).
Demographic data analysis of Group C
In this group, the age of the subjects ranged from
20 to 50 years. Majority of the patients (18/30, 60%)
in this group were in the age group of 41–50  years,
followed by 10/30 in the age group of 31–40  years
(33.33%) and the least patients (2/30, 6.6%) were
in the age group of 21–30  years. Female comprised
66.66% (20/30) of group and males comprised 33.33
(10/30) of the group.
S266 Journal of Pharmacy and Bioallied Sciences  ¦  Volume 11  ¦  Supplement 2  ¦  May 2019
Mean cortisol value analysis
The mean cortisol value in Group A (nonerosive lichen
planus) in the morning was 282.4667 and in the evening
was 253.3333, that in Group B (erosive lichen planus)
in the morning was 563.4000 and in the evening was
497.0000, and that in Group C (control) in the morning
was 255.5000 and in the evening was 235.9667. The
average of morning and evening values of cortisol for
Group A (nonerosive lichen planus) was 267.9000, that
for Group B (erosive lichen planus) was 530.2000, and
that for Group C (control) was 245.733. The mean
serum cortisol levels of the erosive OLP patients (Group
B) were significantly higher than those of nonerosive
OLP patients (Group A) and controls (Group C).
An error bar is drawn to compare the average hormone
level for each group. The bar represents the variability
of the data. In Graph 1, the data point rounded is
the mean of the cortisol level of each group and the
length of the bar represents the confidence interval
(95%). These graphs also help us to compare two
values visually. If they are significantly different they
will not overlap. From the error bar drawn below, it
can be observed that the mean average cortisol levels
are different for the three groups. The erosive group is
having the highest cortisol level followed by nonerosive
group. The control group has the lowest mean hormone
level. But for nonerosive and control groups, there does
not seem much difference in the mean hormone levels.
Paired t test is conducted to find if the difference in the
mean hormone levels in morning and evening is equal
or not. From the descriptive statistics [Table 1], it can
be observed that during both morning and evening,
the mean and standard deviation of the hormone level
are the highest for erosive group whereas they are the
lowest for the control group.
Graph 1: Error bar for average hormone levels
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Jose, et al.: Estimation of serum cortisol levels

From the ANOVA table [Table  2], it can be observed
that the P value is less than 0.05, so the mean hormone
level in the morning (F(2, 57) = 476.045, P value <0.05)
for the three groups is significantly different. Similarly,
for the evening and the average of morning and evening,
it is significantly different.
The means plot in Graph 2 shows that the average of
the morning and evening mean serum cortisol values
varies between different groups (nonerosive, erosive,
and control). From the means plot in Graph 2, it can
be observed that the mean average hormone levels are
different for three groups. The erosive group is having
the highest hormone level followed by nonerosive group.
The control group has the lowest mean hormone level.
Discussion
In this study, an attempt was made to analyze the serum
cortisol levels in patients with erosive and nonerosive
OLP. Also, an attempt was made to compare the serum
cortisol levels between patients with OLP and healthy
patients. The mean serum cortisol analysis between
patients with erosive OLP in comparison to those with
nonerosive OLP (Group A) and controls (Group C)
revealed a significant difference.
Ivanovski et al.[8] measured serum cortisol levels by using
radioimmunoassay. In their study, the serum cortisol
levels in the controls and nonerosive lichen planus
patients were 248.7 ± 10.7 and 250.3 ± 11.1 nmol/L,
respectively whereas in the erosive group, the serum
cortisol level was 536.0 ± 55.6 nmol/L. The results of
their study matches our study. Although a different
method of estimation of serum cortisol was used in
our study compared to the one used by Ivanovski et al.,
the outcome was similar. We used ECL for cortisol
estimation but Ivanovski et al. measured serum cortisol
levels by using radioimmunoassay. Shetty et  al.[9]
conducted a case–control study in 2010 comprising 15
cases each of nonerosive oral lichen planus (NEOLP)
and erosive oral lichen planus (EOLP) and 10 controls.
The serum cortisol levels of all 40 patients were
estimated by using ECL method. We also used ECL
method for serum cortisol estimation. Hospital Anxiety
and Depression Score questionnaire were administered
to evaluate the psychiatric status of all the patients and
found that the mean serum cortisol level of the OLP
group showed a very highly significant difference from
the controls. The difference in the mean cortisol level
between NEOLP group and control was not significant,
whereas it was highly significant between the EOLP
group and controls. A  similar result is observed in
our study also. There was difference in the anxiety
score between the NEOLP and EOLP groups, but the
depression scores between the two groups were not
very significant. These findings suggest that psychiatric
factors play a very important role in the pathogenesis
of OLP and serum cortisol could be a possible indicator
for the erosive nature of the lesion. One of the research
group conducted a study by determining the salivary
cortisol[10] levels in patients under stressful conditions,
whereas the other conducted a study to determine the
average plasma cortisol and 24 hour urine cortisol in
patients with OLP. They stated that their study results
do not support with the hypothesis that environmental

Table 1: Table showing results of paired t test

Paired Differences
95% Confidence Interval
Std. Deviation of the Difference
Group Timing Mean Deviation Lower Upper t df p-value
Non Erosive Morning-Evening 29.13333 29.08330 13.02754 45.23913 3.880 14 .002
Erosive Morning-Evening 66.40000 24.18028 53.00941 79.79059 10.635 14 .000
Control Morning-Evening 19.53333 11.71128 15.16027 23.90640 9.136 29 .000

Table 2: Table showing one-way analysis of variance

Timing Groups Sum of Squares df Mean Square F p-value
Morning Between Groups 1012435.350 2 506217.675 476.045 .000
Within Groups 60612.833 57 1063.383
Total 1073048.183 59
Evening Between Groups 735950.433 2 367975.217 263.684 .000
Within Groups 79544.300 57 1395.514
Total 815494.733 59
Average Between Groups 868599.679 2 434299.840 386.331 .000
Within Groups 64077.367 57 1124.164
Total 932677.046 59

Journal of Pharmacy and Bioallied Sciences  ¦  Volume 11  ¦  Supplement 2  ¦  May 2019 S267
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Jose, et al.: Estimation of serum cortisol levels
Graph 2: Mean plot for average of morning and evening
cortisol level
factors such as stress can have an influence on the
neuroendocrine system through cortisol levels. This
may be due to the difference in study methods.
Although the cortisol levels tested in our study
represent only one possible mechanism for psycho–
neuro–immune interactions, these data suggest that
cortisol and psychological status may play a role that
may influence the pathogenesis of OLP, especially
in the erosive form. Taken together, these may act as
possible avenues by which the psychological status of an
individual may affect the immune system homeostasis
during onset and progression of lichen planus. Results
indicate that the psychological health of the patient
affects the progression of erosive lichen planus.
Conclusion
The following conclusions can be drawn from the study.
OLP was more commonly observed in the middle-aged
group. The serum cortisol levels of patients with erosive
lichen planus were significantly higher in comparison
to those of the controls and patients with nonerosive
lichen planus. This study suggests that serum cortisol
S268 Journal of Pharmacy and Bioallied Sciences  ¦  Volume 11  ¦  Supplement 2  ¦  May 2019
may be a predictor for the erosive nature of OLP and
stress may be an aggravating factor of OLP. The overall
results suggest that changes in serum cortisol levels
correlate with those in the stress levels and the clinical
presentation of OLP, and we need a close collaboration
between physicians, dentists, and counselors/
psychologists to optimize handling of these patients.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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