• Clinical science

Lichen planus

Summary

Lichen planus is a chronic inflammatory disease of unknown origin that is characterized by different types of lesions involving the skin and mucosa in middle-aged individuals. The most common lesions are purple papules with well-demarcated, irregular borders, which typically occur on the wrists, lower extremities, and genitoanal region. The surfaces of the lesions often exhibit a pattern of white lines known as Wickham's striae. The disease is diagnosed clinically, but may be confirmed through dermoscopy and punch biopsies. Biopsy also helps detect squamous cell carcinoma, a possible complication of genital lichen planus. Treatment primarily consists of high-dose topical steroids, but may also include oral steroids and phototherapy in cases of extensive or steroid-refractory disease.

Epidemiology

  • Prevalence: < 1% [1]
  • Age of onset: 30–60 years [2]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

Although the exact etiology of lichen planus is unknown, possible etiologic factors include:

Clinical features

Lichen planus may affect the skin, mucosa, scalp, genitalia, and nails, and presents with varying symptoms depending on the subtype of the disease. The condition is chronic and usually manifests with several relapses. [4]

Cutaneous lichen planus [1]

May occur simultaneously with other subtypes

  • Lesions
    • Purple, well-demarcated papules or plaques
    • Planar (flat-topped)
    • Polygonal, irregular borders
    • Pruritic, often severe
    • Wickham striae: white, reticular lines on the surface of mucosal lesions
  • Distribution pattern
    • Affects the extremities, especially the ankles and flexor wrists, as well as the trunk
    • Lesions arranged in linear or circular groups that may coalesce into larger plaques
    • Bilateral, symmetrical distribution [5]
    • Lesions often develop in previously traumatized skin (Koebner phenomenon)

Mucosal lichen planus

Genital lichen planus

To remember the most important features of lichen Planus, think of the 7 P's: “Pruritic, Polygonal, Planar (flat-topped), Purple Papules, and Plaques.”

Subtypes and variants

Lichen planus can manifest with several subtypes, including: [5]

Diagnostics

Lichen planus is clinically diagnosed based on the presence of typical skin lesions. Additional testing is performed to confirm the diagnosis and rule out other diseases.

Pathology

Differential diagnoses

Lichen sclerosus (et atrophicus) [8][7]

Others

The differential diagnoses listed here are not exhaustive.

Treatment

  • 1. Katta R. Lichen Planus. Am Fam Physician. 2000; 61(11): pp. 3319–3324. pmid: 10865927.
  • 2. Gunnar Wagner, Christian Rose, Michael Max Sachse. Clinical variants of lichen planus. JDDG: Journal der Deutschen Dermatologischen Gesellschaft. 2013. url: https://pubmed.ncbi.nlm.nih.gov/23320493/.
  • 3. Nelson L Rhodus, Bin Cheng, Frank Ondrey. Th1/Th2 cytokine ratio in tissue transudates from patients with oral lichen planus. Mediators of Inflammation. 2007. url: https://pubmed.ncbi.nlm.nih.gov/17497029/.
  • 4. Marks JG Jr, Miller JJ . Lookingbill and Marks' Principles of Dermatology. Saunders Elsevier; 2013.
  • 5. Gorouhi F, Davari P, Fazel N. Cutaneous and mucosal lichen planus: a comprehensive review of clinical subtypes, risk factors, diagnosis, and prognosis. ScientificWorldJournal. 2014. doi: 10.1155/2014/742826.
  • 6. James WD, Berger T, Elston D. Andrews' Diseases of the Skin: Clinical Dermatology. Philadelphia, PA: Elsevier Health Sciences; 2015.
  • 7. Goldstein BG, Goldstein AO, Mostow E, Dellavalle RP, Callen J, Ofori AO. Lichen Planus. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/lichen-planus. Last updated January 11, 2017. Accessed May 17, 2017.
  • 8. Oakley A. Lichen Sclerosus. http://www.dermnetnz.org/topics/lichen-sclerosus/. Updated January 1, 2016. Accessed May 17, 2017.
  • 9. Cooper SM, Arnold SJ, Robert L Barbieri, Callen J, Ofori AO. Vulvar Lichen Sclerosus. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/vulvar-lichen-sclerosus. Last updated June 6, 2016. Accessed April 27, 2017.
  • 10. Jacobe H, Callen J, Ofori AO. Extragenital Lichen Sclerosus. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/extragenital-lichen-sclerosus. Last updated September 6, 2016. Accessed May 17, 2017.
  • 11. Wedel N, Johnson L. Vulvar lichen sclerosus: Diagnosis and management. Journal for Nurse Practitioners. 2014; 10(1): pp. 42–48. doi: 10.1016/j.nurpra.2013.10.009.
  • 12. Susanna K. Fistarol and Peter H. Itin. Diagnosis and Treatment of Lichen Sclerosus. American Journal of Clinical Dermatology. 2013. url: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3691475/.
  • 13. S M Neill, F M Lewis, F M Tatnall, N H Cox. British Association of Dermatologists' guidelines for the management of lichen sclerosus 2010. British Journal of Dermatology. 2010. url: https://pubmed.ncbi.nlm.nih.gov/20854400/.
  • 14. Ziemer M, Mockenhaupt M, Corona R. Lichenoid Drug Eruption (Drug-Induced Lichen Planus). In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/lichenoid-drug-eruption-drug-induced-lichen-planus. Last updated December 9, 2016. Accessed May 17, 2017.
last updated 09/21/2020
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