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lichen planus

Etiology: 1) idiopathic or chronic trauma 2) pharmaceutical agents may induce lichen planus-like eruption (see lichenoid eruption) 3) color film developers may induce lichen planus-like eruption (see lichenoid eruption) 4) chronic graft vs. host reaction 5) dermatomyositis 6) cutaneous manifestation of malignant lymphoma 7) frequently associated with hepatitis C [6,10] Epidemiology: 1) 30-60 years of age; may occur in older women [7]] 2) females > males 3) hypertrophic lichen planus more common in blacks Pathology: - T-cell mediated, chronic inflammatory mucocutaneous condition Genetics: - overexpression of kallikrein-8 Clinical manifestations: 1) flat-topped, violaceous, shiny pruritic papules on the skin - small polygonal violaceous papules [5] - most commonly presents on forearm, wrist & ankles [6] 2) 40-60% of individuals have oropharyngeal involvement a) mucosal involvement frequently includes buccal mucosa, gingiva, tongue, lips, esophagus - commonly affects both oral & vaginal mucosa, but it may present as only a genital lesion (vulvovaginal) b) white papules or lace-like striae (Wickham striae) c) reticular white plaques of the oral mucosa d) hyperkeratosis or painful erosions or ulceration [6] e) dry mouth [7] 3) mucous membrane: may be painful, especially when ulcerated 4) eruption may be acute; duration of lesions months to years 5) skin: asymptomatic to intensely pruritic - occurs in areas of trauma such as scratching (Koebner phenomenon) 6) papules 1-10 mm, sharply defined, rarely bullae 7) hypertrophic plaque, often with post-inflammatory hyperpigmentation 8) violaceous papule with white-line; white reticulated network on buccal mucosa (Wickham's striae) 9) post-inflammatory hyperpigmentation common in dark-skinned individuals 10) grouped, linear [18], annular or scattered discrete lesions 11) distribution: a) flexor aspect of forearm & wrists b) inner aspects of elbows, knees, pretibial region, ankles c) lower back, lumbar region d) eyelids e) scalp f) nails (thickening of nail plate) g) genitalia - vaginal involvement in 70% of women with erosive lichen planus - vulvar scarring - glassy erythematous erosions with white striae along the margins involving the labia minora & vestibule - vaginal scarring with erosions & striae extending into the vagina 12) distribution on sun-exposed sites suggests a) lichen planus actinicus b) lichenoid drug eruption 13) types of lesions a) reticular b) plaque-type c) atrophic d) ulcerative e) bullous 14) papular, annular or ulcerative lesions on glans penis, scrotum, labia, vagina 15) atrophic scalp with scarring alopecia 16) destruction of nail fold & nail bed, especially in large toe * images [11,12,13] Laboratory: - skin biopsy Differential diagnosis: - lichenoid drug eruption - lichen sclerosus (vaginal involvement uncommon) - lichen simplex chronicus (genetically atopic individuals) - vulvar intraepithelial neoplasia (typically visible raised lesion with atypical vascular patterns, but may be flat, white, red, brown, or black) - pityriasis rosea - pityriasis rosea often presents with herald patch - scratching the lichen planus can result in a linear-appearing rash, mimicking appearance of pityriasis rosea - lichen planus is more purple in color than pityriasis rosea - tends to erupt on the lower back - pityriasis rosea tends to erupt on the upper & mid-back - rash on wrist unusual for pityriasis rosea - psoriasis - thick, well-demarcated erythematous plaques with overlying silvery scale - nail psoriasis presents with nail pitting, onycholysis - secondary syphilis - more brownish red in color compared vs purple papules of lichen planus - involves trunk & extremities, often including palms & soles - generalized lymphadenopathy - geographic tongue - appearance of denuded red patches migrating across the surface of the tongue - map-like erythematous patches with white hyperkeratotic rims on dorsal surface of tongue [18] - oral leukoplakia - patches or plaques of the oral mucosa, associated with tobacco or chronic trauma - oral hairy leukoplakia - adherent white plaques, associated with EBV, HIV1 infection Complications: - malignant transformation of oral lesions (SCC) [17] Management: 1) glucocorticoids a) potent topical glucocorticoid (clobetasol) - may decrease pruritus & size of lesions - may not be curative [6] - for local disease (including mucosa), topical treatment is appropriate [7,16] b) intralesional triamcinolone (3 mg/mL) c) oral prednisone 1] begin 70 mg PO QD or 1 mg/kg/day 2] taper by 5 mg QD 3] also consider pulse therapy (GRS9) [7] 2) retinoids a) topical retinoic acid b) acitretin (Soriatane) 1 mg/kg PO QD c) etretinate (Tegison) 1 mg/kg PO QD 3) sulfasalazine 4) PUVA phototherapy 5) calcineurin inhibitors [6] a) topical tacrolimus b) topical pimecrolimus c) cyclosporine 5 mg/kg/day (resistant cases) 6) hydroxychloroquine 7) thalidomide 150-200 mg QHS 8) systemic therapy & phototherapy should be reserved for severe or recalcitrant cutaneous disease [6] - systemic therapy for persistent oral disease [6]

Interactions

disease interactions

Related

lichen sclerosus lichenification lichenoid eruption

Specific

familial lichen planus follicular lichen planus; lichen planopilaris; Graham Little-Piccardi-Lassueur syndrome hypertrophic lichen planus lichen planus actinicus ulcerative lichen planus vesicular lichen planus

General

chronic skin disease (chronic dermatologic disorder, chronic dermatopathy, chronic dermatosis) lichenoid dermatitis

References

  1. DeGowin & DeGowin's Diagnostic Examination, 6th edition, RL DeGowin, McGraw Hill, New York 1994
  2. Harrison's Principles of Internal Medicine, 13th ed. Companion Handbook, Isselbacher et al (eds), McGraw-Hill Inc. NY, 1995, pg 801
  3. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 64
  4. Dereure et al, Arch Dermatol 132:1392 1966
  5. Color Atlas and Synopsis of Clinical Dermatology, Common and Serious Diseases, 3rd ed, Fitzpatrick et al, McGraw Hill, NY, 1997, pg 266-69
  6. Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2009, 2012, 2015, 2018, 2022. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  7. Geriatrics Review Syllabus, American Geriatrics Society, 5th edition, 2002-2004 - Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010 - Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013 - Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016 - Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022
  8. Schlosser BJ. Lichen planus and lichenoid reactions of the oral mucosa. Dermatol Ther. 2010 May-Jun;23(3):251-67. Review. PMID: 20597944
  9. Parashar P. Oral lichen planus. Otolaryngol Clin North Am. 2011 Feb;44(1):89-107 PMID: 21093625
  10. Lodi G, Pellicano R, Carrozzo M. Hepatitis C virus infection and lichen planus: a systematic review with meta-analysis. Oral Dis. 2010 Oct;16(7):601-12 PMID: 20412447
  11. American Academy of Dermatology (image) Lichen planus https://www.aad.org/public/diseases/rashes/lichen-planus
  12. Chuang TY, James WD (images) Medscape: Lichen Planus http://emedicine.medscape.com/article/1123213-overview
  13. DermNet NZ: Lichen planus (images) http://www.dermnetnz.org/scaly/lichen-planus.html
  14. Ebrahimi M, Lundqvist L, Wahlin YB, Nylander E. Mucosal lichen planus, a systemic disease requiring multidisciplinary care: a cross-sectional clinical review from a multidisciplinary perspective. J Low Genit Tract Dis. 2012 Oct;16(4):377-80 PMID: 22622344
  15. McPherson T, Cooper S. Vulval lichen sclerosus and lichen planus. Dermatol Ther. 2010 Sep-Oct;23(5):523-32 PMID: 20868406
  16. Davari P, Hsiao HH, Fazel N. Mucosal lichen planus: an evidence-based treatment update. Am J Clin Dermatol. 2014 Jul;15(3):181-95. Review. PMID: 24781705
  17. 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 Jan;145(1):45-56. Review. PMID: 24379329
  18. NEJM Knowledge+ Dermatology
  19. Ioannides D, Vakirlis E, Kemeny L, et al. European S1 guidelines on the management of lichen planus: a cooperation of the European Dermatology Forum with the European Academy of Dermatology and Venereology. J Eur Acad Dermatol Venereol. 2020;34:1403-14. PMID: 32678513
  20. Day T, Weigner J, Scurry J et al. Classic and hypertrophic vulvar lichen planus. J Low Genit Tract Dis. 2018;22(4):387-395 PMID: 29994816 PMCID: PMC6296835 Free PMC article