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Lichen Planus

para>Children may absorb a proportionally larger amount of topical steroid because of larger skin surface-to-weight ratio.

Second Line

Skin and mucous membranes

  • Intralesional corticosteroids
  • Topical 0.1% tacrolimus (Protopic ointment) BID or topical 1% pimecrolimus (Elidel) cream BID
  • Oral prednisone: used only for a short course (e.g., 30 to 60 mg/day for 2 to 4 weeks) or IM triamcinolone (Kenalog) 40 to 80 mg every 6 to 8 weeksPrecautions with systemic steroidsSystemic absorption of steroids may result in hypothalamic-pituitary-adrenal axis suppression, Cushing syndrome, hyperglycemia, or glucosuria.Increased risk with high-potency topical steroids (i.e., use over large surface area, prolonged use, occlusive dressings)In pregnancy: usually safe, but benefits must outweigh the risks
  • Oral retinoids: Isotretinoin in doses of 10 mg PO daily for 2 months, acitretin 30 mg, or alitretinoin 30 mg PO daily have resulted in improvement in some refractory cases. Observe carefully for resultant dyslipidemia.
  • Oral metronidazole 500 mg BID for 20 to 60 days can be given as a safer alternative to systemic corticosteroids.
  • Cyclosporine may be used in severe cases, but cost and potential toxicity limit its use; topical use for severe oral involvement refractory to other treatments
  • Thalidomide
  • Psoralen ultraviolet-A (PUVA), broad- or narrow-band ultraviolet B (UVB) (5)[A]
  • Griseofulvin (5)[A]
  • Azathioprine
  • Mycophenolate mofetil
  • Metronidazole

ALERT

Avoid oral and topical retinoids during pregnancy.

INPATIENT CONSIDERATIONS

Admission Criteria/Initial Stabilization

Outpatient care

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Patient Monitoring

Serial oral examinations for erosive/ulcerative lesions

PATIENT EDUCATION

  • Oral, erosive, or ulcerative LP: annual follow-up to screen for malignancy (6)[A]
  • Avoid spicy foods, cigarettes, and excessive alcohol.
  • Avoid dry crispy foods such as corn chips, pretzels, and toast.

PROGNOSIS

  • Spontaneous resolution in weeks is possible, but disease may persist for years, especially oral lesions and hypertrophic lesions on the shins.
  • There is a tendency toward relapse.
  • Recurrence in 12 " 20%, especially in those with generalized involvement

COMPLICATIONS

  • Alopecia
  • Nail destruction
  • Squamous cell carcinoma of the mouth or genitals

REFERENCES

11 Shengyuan L, Songpo Y, Wen W, et al. Hepatitis C virus and lichen planus: a reciprocal association determined by a meta-analysis. Arch Dermatol. 2009;145(9):1040 " 1047.22 Arias-Santiago S, Buend a-Eisman A, Aneiros-Fern ‘ndez J, et al. Cardiovascular risk factors in patients with lichen planus. Am J Med. 2011;124(6):543 " 548.33 Cheng S, Kirtschig G, Cooper S, et al. Interventions for erosive lichen planus affecting mucosal sites. Cochrane Database Syst Rev. 2012;(2):CD008092.44 Thongprasom K, Carrozzo M, Furness S, et al. Interventions for treating oral lichen planus. Cochrane Database Syst Rev. 2011;(7):CD001168.55 Atzmony L, Reiter O, Hodak E, et al. Treatments for cutaneous lichen planus: a systematic review and meta-analysis [published online ahead of print October 27, 2015]. Am J Clin Dermatol 2016;17(1):11 " 22.66 Fitzpatrick SG, Hirsch SA, Gordon SC. The malignant transformation of oral lichen planus and oral lichenoid lesions: a systematic review. J Am Dent Assoc. 2014;145(1):45 " 56.

ADDITIONAL READING

  • Fazel N. Cutaneous lichen planus: a systematic review of treatments. J Dermatolog Treat. 2015;26(3):280 " 283.
  • Kolios AG, Marques Maggio E, Gubler C, et al. Oral, esophageal and cutaneous lichen ruber planus controlled with alitretinoin: case report and review of the literature. Dermatology. 2013;226(4):302 " 310.

CODES

ICD10

  • L43.9 Lichen planus, unspecified
  • L43.0 Hypertrophic lichen planus
  • L43.1 Bullous lichen planus
  • L43.8 Other lichen planus

ICD9

697.0 Lichen planus

SNOMED

  • 4776004 Lichen planus (disorder)
  • 68266006 Hypertrophic lichen planus (disorder)
  • 6111009 Bullous lichen planus (disorder)
  • 238658001 Lichen planus of nail (disorder)
  • 238655003 lichen planus of scalp (disorder)

CLINICAL PEARLS

  • Remember the 7 P 's of LP: purple, planar, polygonal, polymorphic, pruritic (not always), papules that heal with postinflammatory hyperpigmentation.
  • Serial oral or genital exams are indicated for erosive/ulcerative LP lesions to monitor for the development of squamous cell carcinoma.
  • An association has been noted between LP and hepatitis C virus infection, chronic active hepatitis, and primary biliary cirrhosis.
  • The "soak and smear " technique can lead to a rapid improvement of symptoms in 1 to 2 days and may obviate the need for systemic steroids.