Lichen planus

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Lichen planus

Mark G. Lebwohl

Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports

image

Lichen planus is a pruritic papulosquamous disease with characteristic histopathologic and clinical features. Oral erosive lichen planus, a painful erosive condition that can affect mucous membranes, is addressed in a separate chapter.

Management strategy

Although lichen planus can resolve spontaneously, treatment is usually demanded by patients, who can be severely symptomatic. Underlying diseases such as hepatitis C or associated drugs should be sought. There are numerous reports of lichen planus developing following vaccinations, particularly for hepatitis B.

In patients with localized disease, superpotent corticosteroids should be applied twice daily for 2 to 4 weeks. If the response is inadequate, intralesional injection of corticosteroids into localized lesions may be beneficial. Topical antipruritic agents containing menthol, phenol, camphor, lidocaine, pramoxine or doxepin hydrochloride can be useful. Oral antihistamines may offer limited benefit in severely pruritic patients. Sedating antihistamines are helpful at bedtime.

Traditionally, patients with extensive lichen planus have been treated with systemic corticosteroids. In recent years oral metronidazole has emerged as a safe and effective alternative to systemic corticosteroids: 500 mg twice daily for 20–60 days has proved effective in many patients. More recently, sulfasalazine has demonstrated efficacy for lichen planus. Patients are started on 500 mg twice daily, and dosage is increased by 500 mg every 3 days until a dose of 2.5 g daily is reached for 3 to 6 weeks. In patients who do not respond, oral prednisone 30–60 mg daily for 2 to 6 weeks, or its equivalent, tapered over the ensuing 2 to 6 weeks, is often effective. Unfortunately, even in patients who clear with systemic corticosteroids, relapses are frequent. If patients require more than two courses of high-dose systemic corticosteroids over the span of a few months, alternative treatments should be sought.

Isotretinoin in doses of 10 mg orally twice daily for 2 months has been reported to clear lichen planus in several patients, and acitretin 30 mg daily has also resulted in marked improvement or remission. In refractory cases, psoralen and UVA (PUVA) or narrowband UVB has demonstrated efficacy in the treatment of lichen planus. PUVA has been particularly beneficial in the lichen planus-like eruption associated with graft-versus-host disease. For severe and refractory lichen planus unresponsive to other therapies, immunosuppressive agents, including cyclosporine, mycophenolate mofetil, methotrexate or azathioprine, are often effective.

Specific investigations

First-line therapies

image Topical corticosteroids C
image Intralesional corticosteroids D
image Antihistamines C

A randomized controlled trial to compare calcipotriol with betamethasone valerate for the treatment of cutaneous lichen planus.

Theng CT, Tan SH, Goh CL, Suresh S, Wong HB, Machin D; Singapore Lichen Planus Study Group. J Dermatol Treat 2004; 15: 141–5.

Fifteen patients were treated with calcipotriol and 16 with betamethasone valerate ointments twice daily for 12 weeks in this randomized open-label trial. Flattening occurred in half the patients, with slightly better improvement that was not statistically significant in the betamethasone-treated patients. There were more cases of local side effects in the calcipotriol-treated patients.

Although topical and intralesional corticosteroids are first-line treatments for lichen planus, their use has been based on anecdotal reports rather than on controlled clinical trials. This is one of very few comparative trials of topical therapies for lichen planus.

Second-line therapies

image Metronidazole B
image Sulfasalazine A
image Systemic corticosteroids B
image Isotretinoin, acitretin A
image Narrowband or broadband UVB C
image PUVA C

Efficacy of sulfasalazine in the treatment of generalized lichen planus: randomized double-blinded clinical trial on 52 patients.

Omidian M, Ayoobi A, Mapar MA, Feily A, Cheraghian B. J Eur Acad Dermatol Venereol 2010; 24: 1051–4.

Forty-four patients completed a double-blind study of sulfasalazine or placebo taken for 3 to 6 weeks. Sulfasalazine doses were started at 1 g per day and increased by 0.5 g every 3 days until a dosage of 2.5 g daily was achieved. Study medications were continued for 3 to 6 weeks. After 6 weeks of treatment, 19 patients (82.6%) in the sulfasalazine group achieved improvement compared to two patients (9.6%) in the placebo group. Pruritus improved in 14.3% of placebo patients and 91.3% in sulfasalazine-treated patients. Mild response (<50% of lesions cleared) occurred in 21.7% of patients in the sulfasalazine group; moderate response (>50% of lesions cleared) in 52.2%; and excellent clearing of lesions (>80%) in 8.7%. Gastrointestinal upset and headache were the most common side effects and occurred in 30.7% of patients, leading three patients to leave the study. Mild skin rash also occurred in one patient.

While complete clearing occurred in a minority of patients, the authors did not continue this study beyond 6 weeks. Perhaps longer therapy would result in greater rates of clearing.

Treatment of lichen planus with acitretin. A double-blind, placebo-controlled study in 65 patients.

Laurberg G, Geiger JM, Hjorth N, Holm P, Hou-Jensen K, Jacobsen KU, et al. J Am Acad Dermatol 1991; 24: 434–7.

Acitretin resulted in marked improvement or remission in 64% of patients compared to 13% of placebo-treated patients in a double-blind trial in 65 subjects. Acitretin doses of 30 mg daily were used, leading to mucocutaneous side effects and hyperlipidemia.

Isotretinoin in doses of 10 mg orally twice daily has been effective in the treatment of oral lichen planus, and anecdotal use suggests efficacy in generalized lichen planus as well. The latter regimen has fewer mucocutaneous side effects than higher doses of acitretin. Restrictions on the use of isotretinoin in the US may make this less practical.

Psoralen plus UVA vs. UVB-311 nm for the treatment of lichen planus.

Wackernagel A, Legat FJ, Hofer A, Quehenberger F, Kerl H, Wolf P. Photodermatol Photoimmunol Photomed 2007; 23: 15–19.

This retrospective chart review compared 15 patients treated with PUVA to 13 patients treated with narrowband UVB. Sixty-seven percent of the PUVA-treated patients achieved complete remission, and 33% achieved a partial clinical response. Thirty-one percent of patients treated with narrowband UVB achieved complete remission and 46% a partial response. The mean duration of therapy was 10.5 weeks for PUVA and 8.2 weeks for narrowband UVB, and the mean number of treatments was 25.9 PUVA treatments compared to 22.5 narrowband UVB treatments. Lichen planus recurred in 47% of PUVA-treated patients but only in 30% of narrowband UVB-treated patients.

Third-line therapies

image Trimethoprim–sulfamethoxazole E
image Griseofulvin E
image Itraconazole C
image Terbinafine E
image Antimalarials E
image Tetracycline or doxycycline C
image Cyclosporine, FK 506 E
image Mycophenolate mofetil E
image Azathioprine E
image Methotrexate C
image Etanercept E
image Adalimumab E
image Photodynamic therapy E
image Nd:YAG laser E
image Interferon E
image 0.1% tacrolimus ointment E
image Pimecrolimus cream E
image Calcipotriol ointment C
image Alitretinoin E
image Thalidomide D
image UVA1 D
image Low molecular weight heparin E

Antimicrobials

Pulsed itraconazole therapy in eruptive lichen planus.

Khandpur S, Sugandhan S, Sharma VK. J Eur Acad Dermatol Venereol 2009; 23: 98–101.

Sixteen patients with eruptive lichen planus were treated with itraconazole 200 mg twice daily pulsed for 1 week each month for 3 months. By the end of the first month, nine of 16 patients (56.25%) stopped developing new lesions. Only nine of the patients were followed for 3 months, and seven of the nine (77.7%) stopped developing new lesions. All of the nine patients reported improvement of pruritus, and five of the nine had complete relief of pruritus. By the end of 3 months, partial flattening was present in six of nine patients (66.66%) and complete flattening in three (33.33%).

Given the partial response seen at 3 months, longer therapy may be warranted.

Systemic immunosuppressive agents

Other

[/level-membership-for-dermatology-category][not-level-membership-for-dermatology-category]

Lichen planus

Mark G. Lebwohl

Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports

image

Lichen planus is a pruritic papulosquamous disease with characteristic histopathologic and clinical features. Oral erosive lichen planus, a painful erosive condition that can affect mucous membranes, is addressed in a separate chapter.

Management strategy

Although lichen planus can resolve spontaneously, treatment is usually demanded by patients, who can be severely symptomatic. Underlying diseases such as hepatitis C or associated drugs should be sought. There are numerous reports of lichen planus developing following vaccinations, particularly for hepatitis B.

In patients with localized disease, superpotent corticosteroids should be applied twice daily for 2 to 4 weeks. If the response is inadequate, intralesional injection of corticosteroids into localized lesions may be beneficial. Topical antipruritic agents containing menthol, phenol, camphor, lidocaine, pramoxine or doxepin hydrochloride can be useful. Oral antihistamines may offer limited benefit in severely pruritic patients. Sedating antihistamines are helpful at bedtime.

Traditionally, patients with extensive lichen planus have been treated with systemic corticosteroids. In recent years oral metronidazole has emerged as a safe and effective alternative to systemic corticosteroids: 500 mg twice daily for 20–60 days has proved effective in many patients. More recently, sulfasalazine has demonstrated efficacy for lichen planus. Patients are started on 500 mg twice daily, and dosage is increased by 500 mg every 3 days until a dose of 2.5 g daily is reached for 3 to 6 weeks. In patients who do not respond, oral prednisone 30–60 mg daily for 2 to 6 weeks, or its equivalent, tapered over the ensuing 2 to 6 weeks, is often effective. Unfortunately, even in patients who clear with systemic corticosteroids, relapses are frequent. If patients require more than two courses of high-dose systemic corticosteroids over the span of a few months, alternative treatments should be sought.

Isotretinoin in doses of 10 mg orally twice daily for 2 months has been reported to clear lichen planus in several patients, and acitretin 30 mg daily has also resulted in marked improvement or remission. In refractory cases, psoralen and UVA (PUVA) or narrowband UVB has demonstrated efficacy in the treatment of lichen planus. PUVA has been particularly beneficial in the lichen planus-like eruption associated with graft-versus-host disease. For severe and refractory lichen planus unresponsive to other therapies, immunosuppressive agents, including cyclosporine, mycophenolate mofetil, methotrexate or azathioprine, are often effective.

Specific investigations

First-line therapies

image Topical corticosteroids C
image Intralesional corticosteroids D
image Antihistamines C

A randomized controlled trial to compare calcipotriol with betamethasone valerate for the treatment of cutaneous lichen planus.

Theng CT, Tan SH, Goh CL, Suresh S, Wong HB, Machin D; Singapore Lichen Planus Study Group. J Dermatol Treat 2004; 15: 141–5.

Fifteen patients were treated with calcipotriol and 16 with betamethasone valerate ointments twice daily for 12 weeks in this randomized open-label trial. Flattening occurred in half the patients, with slightly better improvement that was not statistically significant in the betamethasone-treated patients. There were more cases of local side effects in the calcipotriol-treated patients.

Although topical and intralesional corticosteroids are first-line treatments for lichen planus, their use has been based on anecdotal reports rather than on controlled clinical trials. This is one of very few comparative trials of topical therapies for lichen planus.

Second-line therapies

image Metronidazole B
image Sulfasalazine A
image Systemic corticosteroids B
image Isotretinoin, acitretin A
image Narrowband or broadband UVB C
image PUVA C