Lichen planus

Published on 16/03/2015 by admin

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Last modified 16/03/2015

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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

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