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 weeks
- Precautions with systemic steroids
- Systemic 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.