How would you manage lichen planus localized to the chest wall?

Management of Lichen Planus Localized to the Chest Wall

Ultrapotent topical corticosteroids, specifically clobetasol propionate 0.05% ointment applied twice daily for 2-3 months followed by gradual tapering, are the first-line treatment for lichen planus localized to the chest wall. 1

First-Line Treatment

Topical Corticosteroid Therapy

• Apply clobetasol propionate 0.05% ointment as a thin layer to affected areas twice daily for 2-3 months 1
• Tapering schedule after initial treatment:
  • Once daily for 2 weeks
  • Alternate days for 2 weeks
  • Twice weekly for 2 weeks
  • Once weekly for 2 weeks before discontinuation 1

Important Administration Instructions

• Apply a thin layer only to affected areas
• Wash hands thoroughly after application to avoid spreading medication to sensitive areas (eyes, mouth) 1, 2
• Do not use occlusive dressings as this increases systemic absorption 2
• Total weekly dose should not exceed 50g per week to minimize risk of HPA axis suppression 2

Monitoring and Follow-up

• Schedule follow-up at 3 months to assess response 1
• Monitor for:
  • Clinical improvement (reduction in erythema, pruritus, and lesion thickness)
  • Potential side effects: skin atrophy, telangiectasia, striae 2
  • Signs of systemic absorption with prolonged use (cushingoid features, HPA axis suppression) 2
• If response is satisfactory, final assessment at 6 months 1

Alternative Treatments (for inadequate response to clobetasol)

Second-Line Options

1. Topical calcineurin inhibitors:

   • Tacrolimus 0.1% ointment applied twice daily 1
   • Note: Use with caution due to theoretical concerns about increased risk of neoplasia 1

2. Intralesional corticosteroids:

   • Triamcinolone (10-20 mg/ml) for hyperkeratotic areas resistant to topical therapy 1

3. Systemic therapy (for severe, widespread disease unresponsive to topical treatment):

   • Consider referral to dermatology for systemic options 1

Patient Education

• Avoid irritants and fragranced products 1
• Use emollients as soap substitutes 1
• Inform about the chronic nature of the condition with potential for recurrence
• Reassure that localized cutaneous lichen planus typically resolves within 1-2 years, though recurrences are possible 3

Important Clinical Considerations

• Distinguish lichen planus from lichen sclerosus, as management differs 4
• If lesions become infected, appropriate antifungal or antibacterial therapy should be instituted while continuing steroid treatment 2
• For patients not responding to treatment, consider:
  • Reassessing diagnosis (consider biopsy if not previously done)
  • Evaluating medication compliance
  • Checking for secondary infection

The evidence strongly supports topical ultrapotent corticosteroids as the most effective first-line treatment for localized lichen planus, with studies showing high rates of improvement and symptom control 1, 3. While systemic corticosteroids may be considered for severe, widespread disease, the localized nature of chest wall involvement makes topical therapy the preferred approach with a favorable risk-benefit profile 5, 3.