Lichen Planus

  • Medical Author:
    Gary W. Cole, MD, FAAD

    Dr. Cole is board certified in dermatology. He obtained his BA degree in bacteriology, his MA degree in microbiology, and his MD at the University of California, Los Angeles. He trained in dermatology at the University of Oregon, where he completed his residency.

  • Medical Editor: William C. Shiel Jr., MD, FACP, FACR
    William C. Shiel Jr., MD, FACP, FACR

    William C. Shiel Jr., MD, FACP, FACR

    Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.

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Lichen planus facts

  • Lichen planus is a chronic recurrent rash of unknown cause with no established cure.
  • Lichen planus generally affects adults and can involve any portion of the body, but it has a predilection for the wrists, ankles, and oral and genital tissues.
  • Lichen planus can be quite itchy.
  • Lichen planus may spontaneously resolve.
  • Lichen planus is managed with a variety of topical and oral medications.

What is lichen planus?

Lichen planus is a chronic recurrent rash that is due to inflammation in the skin and mucous membranes. The rash is characterized by small, flat-topped, many-sided (polygonal) bumps that can grow together into rough, scaly plaques on the skin. There may also be a rash in the lining (mucous membranes) of the mouth or vagina.

Lichen planus is a poorly understood skin condition. Its name is descriptive in that to some it resembles a simple plant, a lichen, which grows on rocks and tree bark, while planus is Latin for flat.

What are causes and risk factors for lichen planus?

The cause of lichen planus is unknown. In certain locales, patients with extensive lichen planus seem to be more likely to have a hepatitis C virus infection of the liver. However, it is unclear if this virus is the cause of lichen planus in such situations.

Some drugs, such as those containing arsenic, bismuth, or gold, can produce an eruption which appears identical to lichen planus. Exposure to certain chemicals used in the development of color photographs can also produce a similar rash. The long-term use of the drugs quinacrine or quinidine (Quinidine Gluconate, Quinidine Sulfate), may produce hypertrophic lichen planus of the lower legs. Lichenoid eruptions can occur in graft-versus-host disease in people who have received bone marrow transplants. Tissue examination by a pathologist (biopsy) is frequently necessary to distinguish lichenoid drug eruptions from classical lichen planus. Of course, stopping the offending drug is associated with resolution of the eruption.

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Lichen Planus (Oral) Pictures

Lichen planus (LP) is a common inflammatory disease involving the skin and mucous membranes. Many clinical variants exist that include atrophic, ulcerative, bullous, annular, linear, inverse, hypertrophic, lichen planopilaris, actinic LP and LP pigmentosus.

Oral lichen planus at baseline (left). Two month follow-up after 18 treatments with excimer laser administered weekly (right).

How is the rash of lichen planus different from that of most other common rashes?

Lichen planus can be distinguished from eczema, psoriasis, and other common rashes purely on the basis of its clinical appearance in that lesions are small bumps or aggregations of bumps that are flat-topped, shiny, polygonal, purple to grey in color, tend to occur at the wrists and elbows and ankles, and on close examination contain thin white lines called Wickham's striae. Oral lichen planus involves tissues such as the lips or cheeks; these white filmy lines are easy to detect. It is not unusual for lichen planus to appear at sites of trauma, especially along lines of scratches (excoriations).

What are lichen planus symptoms and signs?

Lichen planus itches with an intensity that varies in different people from mild to severe.

The onset of lichen planus can be sudden or gradual. The first attack may last for weeks or months, and recurrences may happen for years. The bumps at first are 2 mm-4 mm in diameter, with angular borders and a violet color. An excess of pigment (hyperpigmentation) may develop in the affected skin as the lesions persist. Rarely, a patchy, scarring bald (alopecia) area on the scalp occurs.

What does lichen planus look like?

The appearance of lichen planus depends on whether the skin or the lining (mucous membranes) inside the mouth or vagina are affected:

  • Skin involvement: The usual skin involvement with lichen planus consists of flat-topped lilac or violet to brown spots a few millimeters in diameter on the skin. These spots tend to be located on the inner wrists, forearms, the lower legs just above the ankles, and the lower part of the back.
  • A variant of this disease is called hypertrophic lichen planus. This condition appears as thick, reddish-brown lesions that are covered with scales. These spots tend to be on the shins, but they can occur anywhere on the body. This is an especially itchy and persistent (chronic) variant of lichen planus.
  • Atrophic lichen planus produces slightly depressed lesions that otherwise resemble typical lichen planus.
  • Mucous membranes: Lichen planus of the mucous membranes of the mouth and genitalia is common. It appears as a white, lacy rash on the inside of the cheeks or the vagina and may not cause symptoms. The oral rash often occurs prior to any skin involvement. More troublesome, although rare, is erosive lichen planus, which can be quite sore and uncomfortable. This erosive form typically causes the patient to complain of the shallow and often quite painful, recurrent ulcers in the mouth or genitalia. Lichen planus of the female genitalia can involve the external vulvar mucosa and the internal vaginal mucosa. There is an association with cancer in these areas, so both the oral and vaginal tissues need to monitored by a medical professional.
  • Nail malformation may be produced by lichen planus.
  • Lichen planus may involve the scalp, producing a permanent, scarring type of balding.

What physicians diagnose and treat lichen planus?

Most dermatologists, gynecologists, and some oral surgeons diagnose and treat lichen planus.

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How is lichen planus diagnosed?

Usually, lichen planus is relatively straightforward to diagnose. Physicians can make the diagnosis in typical cases simply by looking at the rash. If necessary, a skin biopsy may be done to help confirm the diagnosis because, under the microscope, lichen planus is distinctive in appearance.

Because there are a number of other lichenoid eruptions that resemble lichen planus a biopsy confirmation is frequently necessary. Persistent oral or vaginal lichen planus, with spots that thicken and grow together, can sometimes be difficult to distinguish clinically from whitish precancerous plaques called leukoplakia. A biopsy can be helpful in this situation. There seem to be a few patients in whom ulcerative lichen planus precedes the development of oral cancer.

Are there home remedies for lichen planus?

Although there is little objective evidence of its benefits, green tea has been suggested as a treatment for lichen planus. It is likely to be a safe approach.

What is the treatment for lichen planus?

Most lichen planus is relatively mild. Affected individuals who do not have symptoms do not need treatment. Ultimately, there is no agreed-upon cure for this condition.

If the itch or appearance of the rash are unpleasant, topical corticosteroid creams or topical calcineurin inhibitors like tacrolimus or pimecrolimus may be of help. For localized, itchy, thick lesions, injections of corticosteroids directly into the plaque may helpful. Antihistamines may blunt the itch, particularly if it is only moderate. This effect is in part due to the sedative effect of antihistamines. For oral lesions, topical steroids (cortisone) in special oral preparations are available.

In more severe lichen planus, physicians may recommend oral medications or therapy with ultraviolet light. Oral medications may include a course of oral corticosteroids, such as prednisone or acitretin. Occasionally, other immunosuppressive agents may be employed. However, the itching may return after the drug has been discontinued. A low-dose oral corticosteroid every other morning may be also prescribed. For painful lesions within the mouth, special mouthwashes containing a painkiller (such as lidocaine) before meals may provide some relief. Any drug or chemical suspected of being the cause of the lichen planus should be discontinued.

What is the long-term prognosis of lichen planus??

Lichen planus usually goes away by itself in time. Some drugs can produce rashes that are similar in appearance to lichen planus. These rashes can be distinguished from lichen planus in that they go away when the offending drug is stopped.

Is it possible to prevent lichen planus?

Since the cause of lichen planus is unknown, there are no reliable options to prevent it.

REFERENCES:

Le Cleach, Laurence, and Olivier Chosidow. “Lichen Planus.” The New England Journal of Medicine 366 (2012): 723-732.

Lehman, J.S. "Lichen Planus." International Journal of Dermatology 48.7 (2009): 682-694.

"Lichen Planus." DermNet NZ. Aug. 30, 2011. <http://dermnetnz.org/scaly/lichen-planus.html>.

Sharma, Amit, et al. "Lichen Planus: An Update and Review." Pediatric Dermatology 90 July 2012: 17-23.

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Reviewed on 5/11/2016
References
REFERENCES:

Le Cleach, Laurence, and Olivier Chosidow. “Lichen Planus.” The New England Journal of Medicine 366 (2012): 723-732.

Lehman, J.S. "Lichen Planus." International Journal of Dermatology 48.7 (2009): 682-694.

"Lichen Planus." DermNet NZ. Aug. 30, 2011. <http://dermnetnz.org/scaly/lichen-planus.html>.

Sharma, Amit, et al. "Lichen Planus: An Update and Review." Pediatric Dermatology 90 July 2012: 17-23.

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