What is the treatment for Lichen planus?

Treatment of Lichen Planus

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

First-Line Treatment Algorithm

1. Localized cutaneous lichen planus:

   • Apply clobetasol propionate 0.05% ointment twice daily for 2-3 months 1
   • For adult males: once daily for 1-3 months with emollient as soap substitute 1
   • For adult females: once daily at night for 4 weeks, then alternate nights for 4 weeks, then twice weekly for 4 weeks 1
   • Gradually taper to prevent rebound 1

2. Oral lichen planus:

   • High-potency topical corticosteroids such as clobetasol propionate 0.05% gel 1, 2
   • Apply as a thin layer to affected areas 2-3 times daily 1
   • Consider antifungal prophylaxis (e.g., miconazole) to prevent oral candidiasis 1

3. Genital lichen planus:

   • Ultrapotent topical corticosteroids (clobetasol propionate 0.05%) 1
   • Apply sparingly to affected areas once or twice daily 1
   • Gradually taper frequency after symptom improvement 1

4. Pediatric patients:

   • Use potent (but not ultrapotent) topical corticosteroids for 6-8 weeks 1
   • Avoid ultrapotent steroids due to risk of side effects 1

Alternative Treatments for Resistant Cases

When first-line treatment fails, consider:

1. Topical calcineurin inhibitors:

   • Tacrolimus 0.1% ointment or pimecrolimus 1% cream 1, 2
   • Note: Not recommended as first-line due to concerns about increased risk of neoplasia 1

2. For hyperkeratotic/hypertrophic lesions:

   • Intralesional triamcinolone (10-20 mg) 1
   • Oral retinoids may be beneficial 1, 3

3. Severe, widespread, or resistant cases:

   • Systemic corticosteroids for severe, widespread involvement 2
   • Consider referral to dermatologist for:
     • Acitretin (oral retinoid) 2
     • Immunosuppressants like methotrexate, hydroxychloroquine, cyclosporine, azathioprine, or mycophenolate mofetil 3

4. Other options:

   • Photodynamic therapy for oral lichen planus 1

Monitoring and Follow-up

• Assess clinical improvement through reduction in erythema, pruritus, and lesion thickness 1
• Follow-up at 3 months to assess response and ensure proper application 1
• If response is satisfactory, final assessment 6 months later 1
• Monitor for side effects:
  • Skin atrophy, telangiectasia, and striae 1
  • Signs of systemic absorption with prolonged use 1
  • Biopsy persistent ulcerations to rule out malignant transformation 1

Important Considerations and Pitfalls

• Diagnostic pitfall: Distinguish lichen planus from lichen sclerosus, as management differs 1
• Medication-induced lichenoid reactions: Consider discontinuing potential causative medications including ACE inhibitors, ARBs, anti-arrhythmic drugs, thiazide diuretics, and immune checkpoint inhibitors 1
• Treatment resistance: Mucosal forms (oral, genital) are often more persistent and resistant to treatment than cutaneous forms 2
• Chronic nature: Lichen planus may resolve spontaneously within 1-2 years, but recurrences are common 2
• Patient education: Instruct on proper application technique and hand washing after application 1
• Lifestyle modifications: Avoid irritants and fragranced products; use emollients as soap substitutes 1

Special Situations

• Erosive lichen planus: May require more aggressive therapy due to its recalcitrant nature 4
• Quality of life issues: Address sexual function concerns with genital involvement 1
• Surgical interventions: Generally avoided except for malignancy, post-inflammatory sequelae, or severe complications like introital narrowing 1

Research has shown that topical corticosteroid therapy alone is as effective as systemic corticosteroids followed by topical therapy, with fewer side effects 5. Novel delivery methods, such as applying corticosteroid ointment using cloth strips for mucosal lesions, have shown good efficacy with 96% of patients experiencing improvement or control of symptoms within one year 6.