Published on 16/03/2015 by admin
Filed under Dermatology
Last modified 22/04/2025
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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
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.
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.
Serology for hepatitis B and C
Liver function tests
Drug history
Maticic M, Poljak M, Lunder T, Rener-Sitar K, Stojanovic L. J Eur Acad Dermatol Venereol 2008; 22: 779–88.
Lichen planus was found in 2.3% of 171 hepatitis C virus-seropositive patients, compared to no cases in 171 age- and gender-matched controls.
The association between hepatitis C virus and lichen planus has been controversial, with an association reported in some studied populations but not others.
Thompson DF, Skaehill PA. Pharmacotherapy 1994; 14: 561–71.
β-Blockers, methyldopa, penicillamine, quinidine, quinine, and non-steroidal anti-inflammatory agents play a role in the development of lichen planus. There is insufficient evidence to implicate angiotensin-converting enzyme inhibitors, sulfonylurea agents, carbamazepine, gold, lithium, and other drugs.
Many drugs and chemicals have been associated with lichenoid drug eruptions, which can be difficult to distinguish from true lichen planus. In addition to those mentioned above, hepatitis B and influenza vaccinations, allopurinol, tetracyclines, furosemide, hydrochlorothiazide, isoniazid, phenytoin, and etanercept are reported to cause lichenoid eruptions.
Bjornberg A, Hellgren L. Curr Med Res Opin 1976; 4: 212–17.
Patients with lichen planus that had become resistant to betamethasone valerate ointment were treated with betamethasone dipropionate ointment once or twice daily for 2 to 3 weeks. Fourteen of 19 patients achieved better improvement with betamethasone dipropionate ointment.
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.
Rasi A, Behzadi AH, Davoudi S, Rafizadeh P, Honarbakhsh Y, Mehran M, et al. J Drugs Dermatol 2010; 9: 1186–90.
Forty-nine patients participated in this open trial of oral metronidazole 250 mg every 8 hours for 12 weeks. Twenty patients (40.82%) had a complete response and 16 (32.65%) a partial response. Thirteen (26.53%) did not improve.
Metronidazole has also been studied in a dose of 500 mg twice daily for 20–60 days. The safety of oral metronidazole has led many dermatologists to use this treatment as first-line therapy for lichen planus.
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.
Pitche P, Saka B, Kombate K, Tchangai-Walla K. Ann Dermatol Venereol 2007; 134: 237–40.
Injections of systemic corticosteroids performed at 2-week intervals resulted in complete remission in 61 of 73 (83.6%) patients with lichen planus; 8.2% of patients experienced partial remission, and another 8.2% failed this therapy. At 3 months, the relapse rate of initial responders was 23.3% and at 6 months 31.5% had relapsed.
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.
Pavlotsky F, Nathansohn N, Kriger G, Shapiro D, Trau H. Photodermatol Photoimmunol Photomed 2008; 24: 83–6.
This retrospective analysis reported the results of narrowband UVB in 43 patients with lichen planus and broadband UVB in another seven. Seventy percent achieved complete remission and, at a median of 34.7 months of follow-up, 85% were still in remission.
UVB, and particularly narrowband UVB, has emerged as an effective durable therapy for 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.
Helander I, Jansen CT, Meurman L. Photodermatology 1987; 4: 265–8.
Good or excellent clearing occurred in 10 of 13 patients after eight to 46 bath-PUVA treatments, compared to five of 10 patients after eight to 30 oral PUVA treatments. However, examination of patients months after PUVA suggested that treatment might prolong the duration of lichen planus.
Abdel-Aal H, Abdel-Aal MA. J Egypt Med Assoc 1976; 59: 547–9.
Oral trimethoprim–sulfamethoxazole, two tablets twice daily for 5 days, cleared lichen planus within 2 weeks only to have the skin lesions relapse 2 months later. The trimethoprim–sulfamethoxazole was again effective when re-administered to patients who experienced relapse.
Sehgal VN, Bikhchandani R, Koranne RV, Nayar M, Saxena HM. Dermatologica 1980; 161: 22–7.
Griseofulvin 500 mg/day for 2 months was effective in 18 of 22 patients.
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.
Click JW, Wilson BB. Cutis 2009; 84: 42.
A patient with topical corticosteroid-refractory lichen planus was treated with terbinafine 250 mg daily for 3 weeks and the lichen planus cleared. Upon recurrence of the lichen planus, the terbinafine was again given for 3 weeks. The patient’s lichen planus began to resolve within 3 days of restarting the oral terbinafine. A second patient with lichen planus was treated with ciclopirox olamine cream for tinea pedis and her lichen planus also resolved.
It is unclear why antifungal therapy is effective in the treatment of lichen planus, but there are numerous reports of various antifungal agents working for lichen planus.
Ramírez P, Feito M, Sendagorta E, González-Beato M, De Lucas R. Australas J Dermatol 2012; 53: e10–13.
Lichen planus actinicus is a photosensitive variant that presents in sun exposed areas of the body including the face, V of the neck and arms. This report documents an excellent response to hydroxychloroquine and photoprotection in an 8-year-old girl.
Nousari HC, Goyal S, Anhalt GJ. Arch Dermatol 1999; 135: 1420–1.
Mycophenolate mofetil was reported to successfully treat resistant hypertrophic and bullous lichen planus.
Verma KK, Sirka CS, Khaitan BK. Acta Derm Venereol 1999; 79: 493.
Generalized severe lichen planus has been successfully treated with azathioprine.
Karakatsanis G, Patsatsi A, Kastoridou C, Sotiriadis D. J Eur Acad Dermatol Venereol 2007; 21: 1006–7.
A 63-year-old woman with lichen planus of the palms, forearms, soles, and feet was treated with cyclosporine 3.5 mg/kg daily. Pruritus improved within 2 weeks and clinical improvement occurred within 4 weeks, at which point cyclosporine was tapered over the next 4 weeks.
Turan H, Baskan EB, Tunali S, Yazici S, Saricaoglu H. J Am Acad Dermatol 2009; 60: 164–6.
Eleven patients with generalized lichen planus were treated with methotrexate for 4 to 15 weeks. Initial weekly doses were 15–20 mg and total doses ranged from 65 mg to 175 mg. Complete resolution of skin lesions was achieved in 10 of the 11 patients.
Holló P, Szakonyi J, Kiss D, Jokai H, Horváth A, Kárpáti S. Acta Derm Venereol 2012; 92: 385–6.
A 39-year-old woman with extensive lichen planus refractory to systemic corticosteroids, acitretin, and PUVA was treated with adalimumab 80 mg followed by 40 mg every other week. Pruritus decreased after 2 weeks and skin lesions resolved within 2 months leaving only hyperpigmentation.
Irla N, Schneiter T, Haneke E, Yawalkar N. Case Rep Dermatol 2010; 2: 173–6.
There are a number of case reports of lichen planus of the nails responding to treatment with TNF-α blockers. Unless the nail involvement is treated early, it is difficult to imagine that any therapy would reverse the pterygium that develops in late disease. There are also a number of reports of lichen planus induced by TNF-α blockers.
Kirby B, Whitehurst C, Moore JV, Yates VM. Br J Dermatol 1999; 141: 765–6.
Photodynamic therapy with δ-aminolevulinic acid resulted in clearing of isolated lesions of lichen planus.
Lapidoth M, Arber N, Ben-Amitai D, Hagler J. Acta Derm Venereol 1997; 77: 171–2.
Areias J, Velho GC, Cerqueira R, Barbédo C, Amaral B, Sanches M, et al. Eur J Gastroenterol Hepatol 1996; 8: 825–8.
Given the association between lichen planus and hepatitis C, one might expect interferon to benefit both diseases. There are reports of interferon benefiting patients with lichen planus and exacerbating the condition in others.
Moura AK, Moure ER, Romiti R. Clin Exp Dermatol 2009; 34: 101–3.
Eight patients with cutaneous lichen planus were treated with thalidomide 100 mg daily at bedtime. Three patients withdrew because of transient neuropathy of the legs and transient weakness that began shortly after the treatment started. Five patients noted improvement of pruritus within a few days after starting thalidomide. Skin lesions regressed in a mean of 4 weeks and complete remission was achieved in a mean of 3 months.
Polderman MC, Wintzen M, van Leeuwen RL, de Winter S, Pavel S. J Am Acad Dermatol 2004; 50: 646–7.
Four patients with refractory generalized lichen planus were treated with UVA1 45 J/cm2 5 days per week for two 4-week treatment periods with a 3-week rest in between. All four improved, with one patient achieving 98% clearance.
Fortina AB, Giulioni E, Tonin E. Pediatr Dermatol 2008; 25: 570–1.
A child with lichen planus did not respond to topical corticosteroids but her condition resolved upon treatment with tacrolimus 0.03% ointment.
There are also reports of tacrolimus 0.1% successfully treating lichen planus in adults.
Bayramgürler D, Apaydin R, Bilen N. J Dermatol Treat 2002; 13: 129–32.
For up to 3 months, patients with lichen planus were treated with calcipotriol ointment twice daily to all affected areas except the genitals. Five of 16 (31.25%) experienced complete clearing of lesions, leaving only postinflammatory hyperpigmentation. Partial improvement occurred in four of 16 (25%) of the patients. Seven of 16 (43.75%) did not improve.
Day I, Lin AN. J Cutan Med Surg 2008; 12: 17–26.
Case reports indicate successful use of topical pimecrolimus cream for cutaneous lichen planus.
Yasar S, Serdar ZA, Goktay F, Doner N, Tanzer C, Akkaya D, Gunes P. Indian J Dermatol Venereol Leprol 2011; 77: 64–6.
There are a small number of case reports demonstrating efficacy of low molecular weight heparin for lichen planus.
Kim JE, Won CH, Chang S, Lee MW, Choi JH, Moon KC. J Dermatol 2012; 39: 189–91.
The pigmentary changes of lichen planus are difficult to treat because of the depth of their residual pigment. However, the Nd: YAG laser may be beneficial.
Brehmer F, Haenssle HA, Schön MP, Emmert S. J Am Acad Dermatol 2011; 65: e58–60.
One patient with a 15-year history of cutaneous lichen planus and severe pruritus, a second patient with oral lichen planus, and a third patient with cutaneous and mucocutaneous lichen planus were treated with alitretinoin. The first patient was treated with 30 mg daily and the other two patients were treated with 10 mg daily. All three patients responded dramatically to the alitretinoin within four weeks.
Alitretinoin is a retinoid that was developed for the treatment of hand eczema. There are several case reports of efficacy in the treatment of lichen planus. As with other retinoids, elevation of serum lipids can occur.
Treatment of Skin Disease Comprehensive Therapeutic Strategies 4e
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Topical corticosteroids
Intralesional corticosteroids
Antihistamines
Metronidazole
Sulfasalazine
Systemic corticosteroids
Isotretinoin, acitretin
Narrowband or broadband UVB
PUVA
Trimethoprim–sulfamethoxazole
Griseofulvin
Itraconazole
Terbinafine
Antimalarials
Tetracycline or doxycycline
Cyclosporine, FK 506
Mycophenolate mofetil
Azathioprine
Methotrexate
Etanercept
Adalimumab
Photodynamic therapy
Nd:YAG laser
Interferon
0.1% tacrolimus ointment
Pimecrolimus cream
Calcipotriol ointment
Alitretinoin
Thalidomide
UVA1
Low molecular weight heparin
