Lichen Planus

Essentials

• The aetiology is unknown.
• Present on skin and mucosal membranes
• The diagnosis is usually clinical.
• Recovery is usually spontaneous, but it can be promoted with topical treatments, in severe cases also with systemic medication or phototherapy (narrow-band [NB] UVB, PUVA).

Clinical features

• Bluish-red, flat, glistening, polygonal papules with a pale mesh-like surface (Wickham striae; pictures ).
• Some of the papules may have bullae (l. bullosus).
• On the legs the lesions may become hypertrophic (l. hypertrophicus; pictures ).
• On the mouth mucosa a pale mesh-like surface is typical (pictures ). It may ulcerate.
• The Koebner phenomenon: scratches on the skin become affected with papules
• Typical sites include the volar fold of the wrist, flexor surfaces of the arms, and the ankle (picture ). Common sites also include the proximal palms, soles, lower lip (picture ) and glans penis (picture ). Papules are often distributed on the trunk, especially in the sacral area.
• The lesions are almost invariably itchy.

Diagnostics

• The clinical presentation is usually sufficient for diagnosis.
• Skin biopsy is diagnostic.
• Consider excluding hepatitis C: ALT, HCV antibodies.

Treatment

• An alternative to all modes of treatment is to wait for spontaneous recovery. There is no predictable time-course for spontaneous healing. Imagine yourself in the position of the patient when making treatment decisions.
• Potent corticosteroid preparations often clear the lesions in a couple of weeks.
• Do not use potent steroids without controlling for the outcome!
• In acute exacerbations, oral glucocorticoids may be used as 2-4-week courses, prednisolone 30-60 mg/day, for example.
• Lichen planus on the oral mucosa is difficult to treat. Corticosteroids, retinoids, cyclosporin, or sometimes cryotherapy may be of benefit Glucocorticoid Therapies for Treating Oral Lichen Planus. The possible irritating or sensitizing effect of amalgam fillings may be worth consideration.
• Do not treat pigmented remnants of lichen papules. They return to normal colour spontaneously with time.
• If widespread, active lichen planus is not cured by local treatments a dermatologist may consider light therapies (narrowband UVB or bath PUVA) or systemic drug therapies (acitretin, methotrexate, cyclosporin, hydroxychloroquine, etc.).
• The disease recurs in at least 50% of the patients-often after a few years.

Pictures