LICHEN PLANUS

By Gary M. White, MD

Lichen Planus Multiple flat-topped red, purple papules symmetric on the inner wrists.


Lichen planus (LP) is an inflammatory condition of the skin characterized by lichenoid, purple papules and plaques with a preference for the inner wrists, ankles, feet and low back. It is a T-cell mediated disorder in which the immune system attacks the skin.

Clinical

Itchy, violaceous to purple papules and plaques are typical. The surface often has a characteristic white, lacy pattern, called Wickham's stria. As individual lesions heal, residual pigmentation in the form of post inflammatory hyperpigmentation is common. Koebnerization may occur and pruritus may be intense. The inner wrists, ankles, sides of feet, back, oral mucosa, vulva and penis are favored sites. However, the entire body may be covered in severe cases. Thickened, hypertrophic lesions are more common on the legs. A variant of LP in the sun-exposed areas is called lichen planus actinicus. Milia may develop. Rarely bulla may form. Lesions may follow Blaschko's lines or be zosteriform. The nails may become dystrophic. Very rarely, lesions may occasionally be scaly, putting them in the papulosquamous differential.

Differential/Triggers

An ever-growing number of drugs have been noted to cause lichen planus-like eruptions (see lichenoid drug eruption). These include the new biologics, antimalarials, arsenicals, beta blockers, captopril, furosemide, gold salts, methyl dopa, penicillamine quinidine, sulfonylurea, salsalate and thiazides. One patient's LP was caused by gold-containing cinnamon schnapps. There is some variation in nomenclature. Do these drugs induce lichen planus or do they cause a lichenoid drug eruption? This site has chosen to use the term lichenoid drug eruption.

Liver

Patients with chronic liver disease (e.g. primary biliary cirrhosis, chronic active hepatitis) have twice the risk of developing LP compared with the general population. Some of these patients are infected with Hepatitis B and some with Hepatitis C virus. LP has developed after Hepatitis B vaccination and in association with hepatocellular carcinoma.

Workup

Because of the association with liver disease, screening labs (e.g. Hepatitis B and C, SGPT) should be obtained. In a recent meta study, LP was significantly associated with an increased risk of dyslipidemia and higher triglyceride levels [Int J Dermatol. 2016 Feb 12].

Treatment

For limited disease, a potent topical steroid should be tried along with the admonition not to scratch. A steroid-impregnated tape changed daily (e.g. Cordran) may also help. Alternatively, IL kenalog, e.g. 5-10 mg/cc given monthly may help the patient with limited disease. For more extensive disease, UVB is an excellent approach with minimal side effects.

Oral alitretinoin greatly helped 3 patients with LP refractory to standard topical treatments [JAAD August 2011 Volume 65, Issue 2, Pages e58–e60] as well as patients with oral LP [JEADV 2016;30;293].

Systemic Steroids

Prednisone 40-60 mg/day may be given. The patient should be made aware of its potential side effects. The steroid may be tapered over 1-3 months but recurrences are common. Alternatively, IM triamcinolone 40-60 mg once a month for several months may be effective. Also, pulse therapy may be used. In one case report, 10 tablets of betamethasone 0.5 mg as a single oral dose was given after breakfast on 2 consecutive days every week (5 mg/day x 2 consecutive days per week). Complete arrest of progression, control of itching, and flattening of lesions was achieved within 3 week [J Drugs Dermatol. 2005 Mar-Apr;4(2):218-20]. Alternative options that may or may not be helpful include: isotretinoin, dapsone, acitretin, cyclosporin 5 mg/kg/day, and mycophenolate mofetil.

Additional Pictures

A white, reticulated pattern on the surface--classic Wickham's stria.
Lichen Planus with Wickham's Stria Lichen Planus with Wickham's Stria

The inner wrists and the sides of the feet are the classic spots for Lichen planus.
Lichen Planus Lichen Planus Lichen Planus Lichen Planus

Postinflammatory hyperpigmentation is common.
Lichen Planus with post inflammatory hyperpigmentation Lichen Planus with post inflammatory hyperpigmentation

Classic LP of the buccal mucosa.
Lichen Planus of the buccal mucosa Lichen Planus of the buccal mucosa

Hypertrophic lichen planus and Bullous lichen planus
Hypertrophic Lichen Planus Bullous Lichen Planus

Linear LP occurs, either thru Koebnerization (first photo) or along Blaschko's lines (second photo)
Lichen Planus Koebnerized Lichen Planus following Blaschko's lines

Lichen planus of the soles
Lichen Planus of the soles Lichen Planus of the soles

Lichen Planus of the lips Lichen Planus of the lips

Lichen Planus of the tongue Lichen Planus of the tongue

Erosive Lichen Planus
Lichen Planus of the gums.  Erosive Lichen Planus

Lichen Planus of the nails
Lichen Planus of the nails Lichen Planus of the nails

References

LP may follow Blaschko's lines [Dermatology Online Journal 2015;21;10].

LP of the nails showing polydactylous longitudinal erythronychia , nail plate thinning, onychorrhexis, and mild onycholysis. JAAD January 2011 Volume 64, Issue 1, Pages 167.e1–167.e11

Unilateral LP. October 2007 Volume 57, Issue 4, Pages 690–699

Annular LP in an HIV positive patient. JAAD Case Reports September 2015 Volume 1, Issue 5, Pages 251–253

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