Lichen Planus

Updated: May 12, 2017
  • Author: Tsu-Yi Chuang, MD, MPH, FAAD; Chief Editor: William D James, MD  more...
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Overview

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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Prognosis

The prognosis for lichen planus is good, as most cases regress within 18 months. Some cases recur. In lichen planus, atrophy and scarring are seen in hypertrophic lesions and in lesions on the scalp. Cutaneous lichen planus does not carry a risk of skin cancer, but ulcerative lesions in the mouth, particularly in men, do have a low rate of malignant transformation. However, the malignant transformation rate of oral lichen planus is low (<2% in one report). [16] Vulvar lesions in women may also be associated with squamous cell carcinoma.

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Patient Education

Patients should be told about the self-limiting nature of lichen planus. Because lichen planus is not common, no large, randomized, controlled clinical trials have been conducted for therapy. Several treatments may need to be tried.

Patients should be told about the small likelihood of recurrence and the potential adverse effects from the various treatments offered.

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