Medication Summary
The first-line treatments of cutaneous lichen planus are topical steroids, particularly class I or II ointments. A second choice would be systemic steroids for symptom control and possibly more rapid resolution. Many practitioners prefer intramuscular triamcinolone 40-80 mg every 6-8 weeks. Oral metronidazole has been shown to be an effective therapy for some patients. [9] Oral acitretin has been shown to be effective in published studies. [25] Many other treatments, including mycophenolate mofetil at 1-1.5 g twice daily, are of uncertain efficacy, owing to the paucity of experience. In a randomized double-blinded study, sulfasalazine at up to 2.5 g/day for 6 weeks showed improvement in lesions (>80%) and pruritus (>90%) in patients with generalized lichen planus. [10]
For lichen planus of the oral mucosa, topical steroids are usually tried first. Topical and systemic cyclosporin have been tried with some success [26] ; however, a randomized double-blind study indicated that topical cyclosporin was a less effective but much more costly regimen than clobetasol. [27] Newer topical calcineurin inhibitors have replaced topical cyclosporin for the treatment of lichen planus. Other options include oral or topical retinoids. Even with these effective treatments, relapses are common.
Close monitoring of lipid levels is suggested for patients with lichen planus who are treated with oral retinoid agents because a case control study found that the risk of dyslipidemia in these patients is increased 2-3 fold. [11] In fact, according to a meta-analysis of 5,242 patients, even those who did not receive retinoids might still have dyslipidemia.
Patients with widespread lichen planus may respond to narrow-band or broadband UV-B therapy. [12] Psoralen with UV-A (PUVA) therapy for 8 weeks has been reported to be effective. Risks and benefits of this treatment should be considered. PUVA is carcinogenic. Long-term risks include dose-related actinic degeneration, squamous cell carcinoma, and cataracts. A phototoxic reaction with erythema, pruritus, phytophotodermatitis, and friction blisters could occur.
UV-A therapy combined with oral psoralen consists of oral psoralen (0.6 mg/kg), 1.5-2 hours before ultraviolet light, which usually starts at 0.5-1 J/cm2 and is increased by 0.5 J/cm2 per visit. Use of topical ointment at the time of receiving UV-A treatment may decrease the effectiveness of PUVA. Precaution should be taken for persons with a history of skin cancers or hepatic insufficiency.
Apremilast may be an effective treatment for lichen planus but double-blinded, controlled trials are lacking. [28]
Corticosteroids
Class Summary
These agents have anti-inflammatory properties and cause profound and varied metabolic effects. In addition, these agents modify the body's immune response to diverse stimuli. Topical steroids may be as effective as systemic steroids. Class I or II steroids in ointment form reduce pruritus in cutaneous lichen planus, but they have not been proven to induce remission.
Prednisone
Prednisone may decrease inflammation by reversing increased capillary permeability and suppressing PMN activity. Use with extreme caution in children. The pediatric dose is determined more by severity of the condition than by age or weight.
Betamethasone topical (Diprolene, Celestone, Luxiq)
Betamethasone is for inflammatory dermatosis responsive to steroids. It decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability. Use with extreme caution in pediatric patients. Children have a larger skin surface area to body weight ratio and less developed, thinner skin, which may result in greater amounts of topical steroid being absorbed compared with adults. Use nonfluorinated topical corticosteroids.
Triamcinolone (Aristospan, Kenalog)
Triamcinolone is for inflammatory dermatoses responsive to steroids. It decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability. Local injections have been reported to be effective.
Halobetasol (Ultravate, Halonate)
Halobetasol is used for inflammatory dermatoses responsive to steroids. It decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability. Use with extreme caution in pediatric patients. Children have a larger ratio of skin surface area to body weight and less developed, thinner skin, which may result in greater amounts of topical steroid being absorbed compared with adults. Use nonfluorinated topical corticosteroids.
Retinoid-like Agents
Class Summary
These agents modulate cell proliferation.
Isotretinoin (Amnesteem, Claravis, Myorisan, Sotret)
Isotretinoin is an oral agent that treats serious dermatologic conditions. It is a synthetic 13-cis isomer of the naturally occurring tretinoin (trans- retinoic acid). Both agents are structurally related to vitamin A. Isotretinoin decreases sebaceous gland size and sebum production. It may inhibit sebaceous gland differentiation and abnormal keratinization.
Tretinoin topical (Retin-A, Avita, Renova, Atralin, Tretin-X)
Tretinoin may be effective for oral lichen planus but not for cutaneous disease. It inhibits microcomedo formation and eliminates existing lesions. Tretinoin makes keratinocytes in sebaceous follicles less adherent and easier to remove. It is available as 0.025%, 0.05%, and 0.1% creams and 0.01% and 0.025% gels.
Acitretin (Soriatane)
Acitretin is a retinoic acid analog, like etretinate and isotretinoin. Etretinate is the main metabolite and has demonstrated clinical effects close to those seen with etretinate. Its mechanism of action is unknown.
Immunosuppressants
Class Summary
These agents modulate the immune system.
Cyclosporine (Sandimmune, Neoral, Gengraf)
Topical treatment with cyclosporine under occlusion has been efficacious for genital lesions and may be beneficial in hypertrophic lesions. Mouthwash or oil-based solutions have been effective for oral lichen planus but seem to be no better than corticosteroids. Systemic treatment has been used for severe resistant cutaneous disease, oral or ulcerative foot involvement, and lichen planopilaris of the scalp.
The pediatric population may require higher or more frequent dosing because of accelerated clearance; use with extreme caution.
Antibiotics, Other
Class Summary
These drugs may have antibacterial and/or anti-inflammatory effects that are responsible for their effectiveness in the treatment of cutaneous lichen planus.
Metronidazole (Flagyl)
Oral metronidazole is an imidazole ring-based antibiotic that has been shown to be an effective therapy for some patients presenting with lichen planus. Its mechanism is unknown.
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Lichen planus on the flexor part of the wrist.
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Close-up view of lichen planus.
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Lichen planus shows Wickham striae (white, fine, reticular scales).
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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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Lichen planus lesion. Courtesy of Syed Wali Peeran, with no alterations, Wikimedia Commons (https://commons.wikimedia.org/wiki/File:Lichen_planus-Skin_lesion.jpg).
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Intraoral lichen planus lesion. Courtesy of Syed Wali Peeran, with no alterations, Wikimedia Commons (https://commons.wikimedia.org/wiki/File:Lichen_planus-intra_oral_lesion.jpg).
