What infections are associated with lichen planus and how strong is each association?

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Last updated: September 11, 2026 • View editorial policy

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Infections Associated with Lichen Planus

Hepatitis C virus (HCV), Helicobacter pylori, Candida albicans, Epstein-Barr virus (EBV), and COVID-19 infection show significant associations with lichen planus, with HCV having the strongest and most clinically relevant association, particularly for oral lichen planus.

Strength of Associations by Pathogen

Hepatitis C Virus - Strongest Association

HCV demonstrates the most clinically significant relationship with lichen planus, particularly oral lichen planus (OLP). This association is well-established in clinical practice and can present as eruptive lichen planus with rapid, widespread distribution 1. The relationship is strong enough that HCV screening should be considered in patients presenting with lichen planus, especially oral variants.

Helicobacter pylori - Strong Association

H. pylori infection shows a robust association with OLP, with an odds ratio of 4.69 (95% CI: 1.36-16.19) 2. This meta-analysis demonstrates high heterogeneity but consistent positive association across studies. H. pylori has been documented in oral plaques and saliva, providing a plausible mechanism for this relationship. Testing for H. pylori should be considered in OLP patients, particularly those with erosive disease.

Candida albicans - Moderate to Strong Association

Candida albicans shows significantly higher detection rates in OLP patients compared to healthy controls (OR = 1.74,95% CI: 1.20-2.52) 3. The association is particularly pronounced in erosive OLP (E-OLP), where the odds ratio increases dramatically to 3.97 (95% CI: 2.31-6.84). This suggests that:

  • Candida may be a secondary colonizer in damaged mucosa
  • Erosive variants require more aggressive antifungal consideration
  • The relationship may be bidirectional, with inflammation facilitating fungal overgrowth

Epstein-Barr Virus - Moderate Association

EBV demonstrates a statistically significant association with OLP (OR = 4.41,95% CI: 2.74-7.11) 4. However, this meta-analysis included only moderate-quality studies, and the clinical significance remains unclear. EBV is ubiquitous in the population, making causality difficult to establish. This association should be interpreted cautiously and does not currently warrant routine EBV testing in lichen planus patients.

COVID-19 - Emerging Strong Association

COVID-19 infection and vaccination show a strong association with new-onset lichen planus (conditional OR = 7.50,95% CI: 1.72-32.80) 5. This 2025 matched case-control study from Moscow demonstrates that:

  • Symptomatic COVID-19 infection has a stronger association than vaccination
  • The temporal relationship (≤1 month before diagnosis) suggests a trigger effect
  • This represents an emerging infectious trigger that clinicians should recognize

Important Caveats

Borrelia Controversy

The guideline evidence addresses lichen sclerosus (not planus) and notes controversy regarding Borrelia infection, with no evidence for association in the U.K. and U.S.A., though some European studies suggest possible links 6. This association does not apply to lichen planus and should not be confused.

Distinguishing Association from Causation

These associations do not necessarily imply causation. The relationships may represent:

  • Direct pathogenic triggers
  • Immune dysregulation facilitating both infection and autoimmunity
  • Secondary colonization of damaged tissue (particularly for Candida)

Clinical Algorithm for Infection Screening

For all lichen planus patients:

  1. Screen for HCV, particularly in oral lichen planus
  2. Assess for recent COVID-19 infection or vaccination (within 1 month)

For oral lichen planus specifically: 3. Test for H. pylori infection 4. Evaluate for Candida colonization, especially in erosive disease

Do not routinely test for:

  • EBV (ubiquitous, unclear clinical utility)
  • Borrelia (no established association with lichen planus)

The varying strength of associations across lichen planus subtypes (cutaneous vs. oral vs. genital) emphasizes that infection screening should be tailored to the specific clinical presentation, with oral variants warranting the most comprehensive infectious workup 7.

References

4
Research

The association between Epstein-Barr virus and oral lichen planus: A systematic review and meta-analysis.

Journal of oral pathology & medicine : official publication of the International Association of Oral Pathologists and the American Academy of Oral Pathology, 2020

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.