Lichen Planus

Lichen planus (LP) is a relatively common dermatologic disorder affecting middle-aged individuals. Its cause remains uncertain, although the literature suggests that an autoimmune response (immune response by the body against one of its own tissues, cells, or molecules) may be involved. There have been reported cases of lichen planus-like lesions that occur as an allergic reaction to certain types of medications, most commonly medications for arthritis, high blood pressure and heart disease. LP has been associated with hepatitis C, which can be determined with blood work ordered by your physician.

Presentation:
LP can affect the skin, nails, mucous membranes and genital skin. LP of the skin classically presents as an itchy, purple, scaly, flat-topped, bumpy rash. The color is pink to red initially, eventually becoming violaceous (reddish-purple). The surface often has gray or white lacy streaks (Wickham’s striae) which cross the lesions. LP of the nails most commonly presents with splitting and longitudinal ridging. LP of the mucous membranes presents with white lacy streaks on the inside of the cheeks (most common), tongue, lips and gums. Less commonly, LP of the mouth could present with painful ulcers.

Treatment:
LP does not have a cure and treatment should be individualized on a patient to patient basis. Skin lesions, if not widespread, can be treated with topical steroids or steroids injected into the lesion. For itching, topical anti-itching creams/lotions/soaks may provide some relief (Sarna and Aveeno oatmeal bath). Oral anti-itch pills may be necessary if itching is more severe. If LP is more extensive, oral steroids for many weeks may provide some benefit. In addition, phototherapy (PUVA), oral retinoids (vitamin A derivatives), and cyclosporine (an immunosuppressive agent) may be considered.

Oral lesions of LP provide an even greater challenge. Treatment options include super-potent steroids in a gel form, and steroids injected into specific lesions. LP of the nails provides another great challenge, with treatment options being very limited and not greatly effective. Steroid injections have been used for some of these cases. Severe involvement may result in permanent destruction of the nail.

References:
Boyd AS and Neldner KH: Lichen planus. J Am Acad Dermatol 1991;25:593-619.
Champion RH. Textbook of Dermatology. 6th Ed. Eds: Rook, Wilkinson, Ebling. Blackwell Science: Mass.,1998:199-1916.
Cribier B, Frances C, Chosidow O: Treatment of lichen planus. An evidence-based medicine analysis of efficacy. Arch Dermatol 1998 Dec; 134: 1521-30.
Fitzpatrick T, Eisen A, Wolff K, et al: Dermatology in General Medicine. Vol 1. 4th ed. McGraw-Hill:New York, 1993:1134-44.

Mollie Jan, D.O.
Department of Dermatology
Philadelphia College of Osteopathic Medicine/Frankford Hospital
Philadelphia, Pennsylvannia.