What is the treatment approach for lichen planus?

Treatment Approach for Lichen Planus

High-potency topical corticosteroids are the first-line treatment for all forms of lichen planus, including cutaneous, oral, and genital presentations. 1

Clinical Presentation and Differential Diagnosis

Lichen planus presents with characteristic features:

• Violaceous (dark red/purple) papules and plaques without scale on trunk and extremities
• Significant pruritus
• Possible erosions and striae in oral and vulvar mucosa
• Wickham striae (lacy, reticular white lines) often visible on lesions 2

Differential diagnosis includes:

• Psoriasis (thicker, scaly plaques on extensor surfaces)
• Lichenoid drug reactions
• Lichen sclerosus (more atrophic, whitish lesions)
• Contact dermatitis
• Mucous membrane pemphigoid (for oral lesions)

Treatment Algorithm Based on Disease Severity

Mild Disease (Limited Cutaneous Involvement)

• First-line: High-potency topical corticosteroids (clobetasol 0.05% or fluocinonide 0.05%) 1, 3
  • Apply once daily until improvement, then taper to twice weekly
  • Choose formulation based on site: gel for mucosal disease, solution for scalp, cream/ointment for other areas 1
• Alternative: Topical calcineurin inhibitors (tacrolimus 0.1% ointment) 1, 2
• Adjunctive: Oral antihistamines for pruritus 1

Moderate Disease (Widespread Cutaneous or Symptomatic Mucosal)

• First-line: High-potency topical corticosteroids as above 1
• Add: Oral antihistamines for pruritus 1
• Add: Narrow-band UVB phototherapy (if available) 1
• Consider: Short course of oral prednisone if rapid control needed 1, 4
  • Typically 0.5-1 mg/kg/day for 1-2 weeks with taper

Severe Disease (Extensive or Refractory)

• First-line: Oral prednisone or IV methylprednisolone 1
• Second-line options (steroid-sparing):
  • Acitretin (if no childbearing potential) 1, 2
  • Doxycycline with nicotinamide 1
  • Immunosuppressants: azathioprine, cyclosporine, hydroxychloroquine, methotrexate, or mycophenolate mofetil 1, 5
• Dermatology referral strongly recommended 1

Site-Specific Considerations

Oral Lichen Planus

• High-potency topical corticosteroid gel (clobetasol 0.05%) 1, 4
  • Apply directly to lesions 2-3 times daily
  • Consider mixing with adhesive base for better retention
• Monitor for oral candidiasis; consider prophylactic antifungals 4
• Topical tacrolimus as alternative 2

Genital Lichen Planus

• High-potency topical corticosteroid ointment (clobetasol 0.05%) 1, 3
• Apply once daily at night for 4 weeks, then alternate nights for 4 weeks, then twice weekly 3
• For vulvovaginal disease, consider topical tacrolimus as adjunctive therapy 2

Scalp Lichen Planus (Lichen Planopilaris)

• High-potency topical corticosteroid solution 1, 3
• Consider intralesional corticosteroid injections for resistant areas 5
• Early systemic therapy often needed to prevent permanent hair loss 5

Monitoring and Follow-up

• Assess response after 4-6 weeks of treatment 3
• For well-controlled disease, follow-up every 6-12 months 1
• For refractory disease, more frequent monitoring and dermatology referral 1

Important Considerations and Pitfalls

1. Treatment duration: Lichen planus may resolve spontaneously within 1-2 years, but mucosal forms tend to be more persistent and resistant to treatment 2

2. Steroid side effects: Monitor for skin atrophy, telangiectasia, and secondary infections with prolonged topical steroid use 4

3. Treatment failure: Consider:

   • Incorrect diagnosis (biopsy if uncertain)
   • Superimposed conditions (contact allergy, infection)
   • Non-adherence to treatment regimen 1

4. Malignant transformation: While rare, there is a small risk of squamous cell carcinoma in long-standing oral and genital lichen planus; persistent ulcerations should be biopsied 1

5. Psychosocial impact: Address quality of life issues, especially with genital involvement that may affect sexual function 1