By Gary M. White, MD
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.
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.
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.
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.
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].
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].
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.
A white, reticulated pattern on the surface--classic Wickham's stria.
The inner wrists and the sides of the feet are the classic spots for Lichen planus.
Postinflammatory hyperpigmentation is common.
Classic LP of the buccal mucosa.
Hypertrophic lichen planus and Bullous lichen planus
Linear LP occurs, either thru Koebnerization (first photo) or along Blaschko's lines (second photo)
Lichen planus of the soles
Erosive Lichen Planus
Lichen Planus of the nails
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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