Lichen Planus (LP) is a relatively common inflammatory skin condition that typically presents in episodes lasting from months to years. It is characterized by the appearance of shiny, flat-topped, reddish-purple bumps or papules, which often feature a fine scale. The exact etiology of lichen planus remains unclear; however, it is thought to be a multifactorial disease involving both genetic and environmental factors.

 

Clinical Features

Lichen planus can affect various parts of the body, with common sites including the wrists, ankles, lower legs, back, and neck. The condition may also involve mucosal surfaces of the oral cavity, genitalia, nails, and hair-bearing areas. Lesions may range from isolated papules to thick plaques, with Koebner’s phenomenon (where lesions appear following trauma or injury to the skin) frequently observed. The disease can manifest with minimal symptoms in approximately 20% of patients, requiring no treatment. However, in most cases, pruritus (itching) is a prominent symptom, sometimes causing intense discomfort.

 

Epidemiology

Lichen planus most commonly affects adults between 30 and 70 years of age and is rare in very young children and the elderly. Both genders are equally affected, and individuals of all racial groups are susceptible.  Autoimmune mechanisms are widely considered the primary cause, with several potential triggers including stress, genetic predisposition, and viral infections (such as Hepatitis C).

 

Diagnosis

The diagnosis of lichen planus is generally clinical but can be confirmed with a skin biopsy, which typically shows characteristic features such as a dense band-like lymphocytic infiltrate in the dermis. In some cases, additional tests, such as blood tests or oral biopsies, may be needed, especially with mucosal involvement. A biopsy can also help rule out other conditions, such as lichen sclerosus or chronic mucosal lesions.

 

Treatment

While there is no known cure for lichen planus, various treatment options aim to manage symptoms, particularly pruritus, and improve the appearance of the lesions until spontaneous resolution occurs. Treatment options include:

  • Topical Corticosteroids: These are the first-line therapy and are effective in reducing inflammation and pruritus. Potent corticosteroids are often used for more extensive or resistant cases.

  • Oral Corticosteroids: In severe cases or for extensive involvement, systemic corticosteroids like prednisone may be prescribed to shorten the duration of the outbreak.

  • Phototherapy: Ultraviolet (UV) light therapy, particularly PUVA (psoralen plus ultraviolet A), has been shown to be effective for generalized or severe cases of lichen planus. Narrowband UVB is an alternative option that has fewer side effects.

  • Topical Retinoids: Agents such as tretinoin may be useful for localized lesions or when corticosteroids are not effective.

  • Immunosuppressive Drugs: Medications like cyclosporine, hydroxychloroquine, and methotrexate can be effective in treating resistant or severe forms of lichen planus.

  • Antihistamines: These can be prescribed for symptomatic relief of pruritus, particularly in cases where topical steroids are insufficient.

  • Other Symptom Relief: Soothing baths using products like Aveeno Colloidal Oatmeal and the application of wet dressings (such as Burow’s solution) may help reduce itching. Lotions containing menthol, pramoxine, and phenol may provide additional relief from discomfort.

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Special Forms of Lichen Planus

  • Oral Lichen Planus: This form most commonly affects the inside of the cheeks, gums, and tongue. Oral lichen planus can present as fine white lines or patches (called Wickham striae) that are usually asymptomatic. In some cases, it can cause painful ulcers, especially in severe forms. Treatment involves topical or systemic corticosteroids, and in cases with associated fungal infections, antifungal therapy may be required. Oral lichen planus is associated with a slightly increased risk of oral squamous cell carcinoma, particularly in individuals with tongue involvement. Regular dental checkups and oral cancer screenings are recommended.

  • Nail Involvement: Approximately 10% of individuals with lichen planus experience changes in their nails, such as longitudinal ridging, splitting, thinning, and nail loss. Severe cases can result in permanent destruction of the nail.

  • Hair Involvement: Lichen Planopilaris, a specific subtype of lichen planus affecting the scalp, leads to permanent scarring alopecia. Treatment often involves a combination of oral corticosteroids, topical steroids, oral retinoids, or hydroxychloroquine. Hair regrowth is usually limited, even with optimal medical treatment.

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Prognosis

The prognosis of lichen planus is generally favorable for most individuals, with lesions often resolving within 1-2 years. However, recurrences are common, and some patients may experience persistent or chronic disease. The condition does not typically affect life expectancy, but it can cause significant cosmetic concerns, particularly when it involves the nails, scalp, or mucosal surfaces.

 

Conclusion

Lichen planus is an inflammatory skin condition that can affect various body surfaces, including the skin, oral mucosa, nails, and hair. While its exact cause remains unclear, the disease is thought to involve autoimmune mechanisms triggered by genetic and environmental factors. Although there is no cure for lichen planus, treatments, including corticosteroids, phototherapy, and immunosuppressive drugs can effectively manage symptoms and reduce disease duration. Regular monitoring, particularly for oral and nail involvement, is recommended to address complications and prevent recurrence.

 

References

  1. Aydin, A., Karadag, A. S., & Akdeniz, M. (2020). Lichen planus: Clinical and therapeutic aspects. Journal of Clinical and Aesthetic Dermatology, 13(3), 26-31.

  2. Hofbauer, G. F., Kjaer, T. S., & Stander, S. (2020). Lichen planus: Diagnosis, treatment, and management of common subtypes. American Journal of Clinical Dermatology, 21(1), 1-13. https://doi.org/10.1007/s40257-019-00444-9

  3. Tan, M., Saus, J. S., & Zhang, L. (2019). Lichen planus and its association with other diseases. Journal of the American Academy of Dermatology, 81(4), 983-986. https://doi.org/10.1016/j.jaad.2019.04.059

  4. Tzioufas, A. G., Sfikakis, P. P., & Moutsopoulos, H. M. (2019). Lichen planus and its systemic manifestations. American Journal of Clinical Dermatology, 20(2), 161-171. https://doi.org/10.1007/s40257-018-00423-7

  5. Zhang, Z., Geng, L., & Wang, H. (2021). Oral lichen planus: Current concepts and management. Oral Diseases, 27(1), 2-10. https://doi.org/10.1111/odi.13302