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Lichen Planus

  • Author: Tsu-Yi Chuang, MD, MPH, FAAD; Chief Editor: William D James, MD  more...
 
Updated: Mar 01, 2016
 

Practice Essentials

Lichen planus is a cell-mediated immune response of unknown origin. It may be found with other diseases of altered immunity, such as ulcerative colitis, alopecia areata, vitiligo, dermatomyositis, morphea, lichen sclerosis, and myasthenia gravis. Lichen planus (see the image below) has been found to be associated with hepatitis C virus infection.[1, 2, 3, 4, 5]

Close-up view of lichen planus. Close-up view of lichen planus.

Signs and symptoms

The following may be noted in the patient history:

  • Lesions initially developing on flexural surfaces of the limbs, with a generalized eruption developing after a week or more and maximal spreading within 2-16 weeks
  • Pruritus of varying severity, depending on the type of lesion and the extent of involvement
  • Oral lesions that may be asymptomatic, burning, or even painful
  • In cutaneous disease, lesions typically resolve within 6 months (>50%) to 18 months (85%); chronic disease is more likely oral lichen planus or with large, annular, hypertrophic lesions and mucous membrane involvement

In addition to the widespread cutaneous eruption, lichen planus can involve the following structures:

  • Mucous membranes
  • Genitalia
  • Nails
  • Scalp

The clinical presentation of lichen planus has several variations, as follows:

  • Hypertrophic lichen planus
  • Atrophic lichen planus
  • Erosive/ulcerative lichen planus
  • Follicular lichen planus (lichen planopilaris)
  • Annular lichen planus
  • Linear lichen planus
  • Vesicular and bullous lichen planus
  • Actinic lichen planus
  • Lichen planus pigmentosus
  • Lichen planus pemphigoides

See Clinical Presentation for more detail.

Diagnosis

Direct immunofluorescence study reveals globular deposits of immunoglobulin M (IgM) and complement mixed with apoptotic keratinocytes. No imaging studies are necessary.

Distinguishing histopathologic features of lichen planus include the following:

  • Hyperkeratotic epidermis with irregular acanthosis and focal thickening in the granular layer
  • Degenerative keratinocytes (colloid or Civatte bodies) in the lower epidermis; in addition to apoptotic keratinocytes, colloid bodies are composed of globular deposits of IgM (occasionally immunoglobulin G [IgG] or immunoglobulin A [IgA]) and complement
  • Linear or shaggy deposits of fibrin and fibrinogen in the basement membrane zone
  • In the upper dermis, a bandlike infiltrate of lymphocytic (primarily helper T) and histiocytic cells with many Langerhans cells

See Workup for more detail.

Management

Lichen planus is a self-limited disease that usually resolves within 8-12 months. Mild cases can be treated with fluorinated topical steroids. More severe cases, especially those with scalp, nail, and mucous membrane involvement, may necessitate more intensive therapy.

Pharmacologic therapies include the following:

  • Cutaneous lichen planus: Topical steroids, particularly class I or II ointments (first-line treatment); systemic steroids; oral regimens like metronidazole, acitretin, methotrexate, hydroxychloroquine, griseofulvin, and sulfasalazine [6, 7, 8, 9] ; and other treatments with unproven efficacy (eg, mycophenolate mofetil)
  • Lichen planus of the oral mucosa: Topical steroids; topical calcineurin inhibitors; oral or topical retinoids (with close monitoring of lipid levels [10] )

Patients with widespread lichen planus may respond to the following:

  • Narrow-band or broadband UV-B radiation [11, 6, 7]
  • Psoralen with UV-A (PUVA) radiation; [6, 7] use of topical ointment at the time of UV-A treatment may decrease the effectiveness of PUVA; precautions should be taken for persons with a history of skin cancers or hepatic insufficiency

See Treatment and Medication for more detail.

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Background

Lichen planus (LP) is a pruritic eruption commonly associated with hepatitis C. Lesions are characteristically papular, purple (violaceous color), polygonal, and peripherally located (eg. on the distal extremities). LP may also affect the genitalia or mucous membranes. It is most likely an immunologically mediated reaction, though the pathophysiology in unclear. See Oral Lichen Planus for more information on this variant of lichen planus.

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Pathophysiology

Lichen planus is a cell-mediated immune response of unknown origin. It may be found with other diseases of altered immunity; these conditions include ulcerative colitis, alopecia areata, vitiligo, dermatomyositis, morphea, lichen sclerosis, and myasthenia gravis.

An association is noted between lichen planus and hepatitis C virus infection,[2, 3, 4, 5] chronic active hepatitis, and primary biliary cirrhosis.[12] In one meta-analysis, 16% of patients with LP had hepatitis C infection.[3] This association has been shown to exist in all regions of the world, including North America.[4] A workup for hepatitis C should be considered in patients with widespread or unusual presentations of lichen planus. Onset or exacerbation of lichen planus has also been linked to stressful events.[13]

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Epidemiology

Frequency

United States

Lichen planus is reported in approximately 1% of all new patients seen at health care clinics. Some areas have reported a higher incidence in December and January.

International

No significant geographical variation in frequency exists for lichen planus.

Race

No racial predispositions have been noted for lichen planus.

Sex

No significant differences in incidence for lichen planus are noted between male and female patients, but in women, lichen planus may present as desquamative inflammatory vaginitis.[14]

Age

More than two thirds of lichen planus patients are aged 30-60 years; however, lichen planus can occur at any age.[15]

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Contributor Information and Disclosures
Author

Tsu-Yi Chuang, MD, MPH, FAAD Clinical Professor, Department of Dermatology, Keck School of Medicine of the University of Southern California; Dermatologist, HealthCare Partners

Tsu-Yi Chuang, MD, MPH, FAAD is a member of the following medical societies: American Academy of Dermatology, American Society for Dermatologic Surgery, International Society of Dermatology

Disclosure: Nothing to disclose.

Coauthor(s)

Laura Stitle, MD Staff Physician, Department of Dermatology, Indiana University Medical Center

Laura Stitle, MD is a member of the following medical societies: Alpha Omega Alpha

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Warren R Heymann, MD Head, Division of Dermatology, Professor, Department of Internal Medicine, Rutgers New Jersey Medical School

Warren R Heymann, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Joshua A Zeichner, MD Assistant Professor, Director of Cosmetic and Clinical Research, Mount Sinai School of Medicine; Chief of Dermatology, Institute for Family Health at North General

Joshua A Zeichner, MD is a member of the following medical societies: American Academy of Dermatology, National Psoriasis Foundation

Disclosure: Received consulting fee from Valeant for consulting; Received grant/research funds from Medicis for other; Received consulting fee from Galderma for consulting; Received consulting fee from Promius for consulting; Received consulting fee from Pharmaderm for consulting; Received consulting fee from Onset for consulting.

References
  1. Alaizari NA, Al-Maweri SA, Al-Shamiri HM, Tarakji B, Shugaa-Addin B. Hepatitis c virus infections in oral lichen planus: a systematic review and meta-analysis. Aust Dent J. 2015 Oct 17. [Medline].

  2. Chuang TY, Stitle L, Brashear R, Lewis C. Hepatitis C virus and lichen planus: A case-control study of 340 patients. J Am Acad Dermatol. 1999 Nov. 41(5 Pt 1):787-9. [Medline].

  3. Shengyuan L, Songpo Y, Wen W, Wenjing T, Haitao Z, Binyou W. Hepatitis C virus and lichen planus: a reciprocal association determined by a meta-analysis. Arch Dermatol. 2009 Sep. 145(9):1040-7. [Medline].

  4. Bigby M. The relationship between lichen planus and hepatitis C clarified. Arch Dermatol. 2009 Sep. 145(9):1048-50. [Medline].

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  6. Atzmony L, Reiter O, Hodak E, Gdalevich M, Mimouni D. Treatments for Cutaneous Lichen Planus: A Systematic Review and Meta-Analysis. Am J Clin Dermatol. 2016 Feb. 17(1):11-22. [Medline].

  7. Fazel N. Cutaneous lichen planus: A systematic review of treatments. J Dermatolog Treat. 2015 Jun. 26(3):280-3. [Medline].

  8. Rasi A, Behzadi AH, Davoudi S, Rafizadeh P, Honarbakhsh Y, Mehran M, et al. Efficacy of oral metronidazole in treatment of cutaneous and mucosal lichen planus. J Drugs Dermatol. 2010 Oct. 9(10):1186-90. [Medline].

  9. Omidian M, Ayoobi A, Mapar M, Feily A, Cheraghian B. Efficacy of sulfasalazine in the treatment of generalized lichen planus: randomized double-blinded clinical trial on 52 patients. J Eur Acad Dermatol Venereol. 2010 Feb 10. [Medline].

  10. Arias-Santiago S, Buendia-Eisman A, Aneiros-Fernandez J, et al. Cardiovascular risk factors in patients with lichen planus. Am J Med. 2011 Jun. 124(6):543-8. [Medline].

  11. Pavlotsky F, Nathansohn N, Kriger G, Shpiro D, Trau H. Ultraviolet-B treatment for cutaneous lichen planus: our experience with 50 patients. Photodermatol Photoimmunol Photomed. 2008 Apr. 24(2):83-6. [Medline].

  12. Korkij W, Chuang TY, Soltani K. Liver abnormalities in patients with lichen planus. A retrospective case-control study. J Am Acad Dermatol. 1984 Oct. 11(4 Pt 1):609-15. [Medline].

  13. Manolache L, Seceleanu-Petrescu D, Benea V. Lichen planus patients and stressful events. J Eur Acad Dermatol Venereol. 2008 Apr. 22(4):437-41. [Medline].

  14. Murphy R, Edwards L. Desquamative inflammatory vaginitis: what is it?. J Reprod Med. 2008 Feb. 53(2):124-8. [Medline].

  15. Balasubramaniam P, Ogboli M, Moss C. Lichen planus in children: review of 26 cases. Clin Exp Dermatol. 2008 Jul. 33(4):457-9. [Medline].

  16. Belfiore P, Di Fede O, Cabibi D, et al. Prevalence of vulval lichen planus in a cohort of women with oral lichen planus: an interdisciplinary study. Br J Dermatol. 2006 Nov. 155(5):994-8. [Medline].

  17. Di Fede O, Belfiore P, Cabibi D, et al. Unexpectedly high frequency of genital involvement in women with clinical and histological features of oral lichen planus. Acta Derm Venereol. 2006. 86(5):433-8. [Medline].

  18. Cribier B, Frances C, Chosidow O. Treatment of lichen planus. An evidence-based medicine analysis of efficacy. Arch Dermatol. 1998 Dec. 134(12):1521-30. [Medline].

  19. Lim KK, Su WP, Schroeter AL, Sabers CJ, Abraham RT, Pittelkow MR. Cyclosporine in the treatment of dermatologic disease: an update. Mayo Clin Proc. 1996 Dec. 71(12):1182-91. [Medline].

  20. Conrotto D, Carbone M, Carrozzo M, et al. Ciclosporin vs. clobetasol in the topical management of atrophic and erosive oral lichen planus: a double-blind, randomized controlled trial. Br J Dermatol. 2006 Jan. 154(1):139-45. [Medline].

  21. Paul J, Foss CE, Hirano SA, Cunningham TD, Pariser DM. An open-label pilot study of apremilast for the treatment of moderate to severe lichen planus: A case series. J Am Acad Dermatol. 2013 Feb. 68(2):255-61. [Medline].

  22. Gonzalez-Moles MA, Scully C, Gil-Montoya JA. Oral lichen planus: controversies surrounding malignant transformation. Oral Dis. 2008 Apr. 14(3):229-43. [Medline].

  23. Knackstedt TJ, Collins LK, Li Z, Yan S, Samie FH. Squamous Cell Carcinoma Arising in Hypertrophic Lichen Planus: A Review and Analysis of 38 Cases. Dermatol Surg. 2015 Dec. 41(12):1411-8. [Medline].

  24. Ingafou M, Leao JC, Porter SR, Scully C. Oral lichen planus: a retrospective study of 690 British patients. Oral Dis. 2006 Sep. 12(5):463-8. [Medline].

  25. Lai YC, Yew YW, Schwartz RA. Lichen planus and dyslipidemia: a systematic review and meta-analysis of observational studies. Int J Dermatol. 2016 Feb 12. [Medline].

 
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Lichen planus on the flexor part of the wrist.
Close-up view of lichen planus.
Lichen planus shows Wickham striae (white, fine, reticular scales).
Lichen planus on the oral mucosa with ulceration in the center of the lesion appears with whitish papules and plaques in the periphery.
 
 
 
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