What medications can cause lichenoid drug reactions?

Medications That Can Cause Lichenoid Drug Reactions

Numerous medications across different drug classes can trigger lichenoid drug reactions, with thiazide diuretics, antimalarials, beta-blockers, and ACE inhibitors being among the most commonly implicated agents. 1, 2, 3

Common Medication Classes Associated with Lichenoid Drug Reactions

Cardiovascular Medications

• Antihypertensives:

  • ACE inhibitors: ramipril, enalapril, quinapril 1
  • Angiotensin receptor blockers: candesartan, irbesartan, losartan, olmesartan, telmisartan, valsartan 1
  • Beta-blockers (particularly common): tilisolol and others 1, 2, 3
  • Calcium channel blockers: amlodipine, diltiazem, nifedipine 1
  • Methyldopa 4, 2
  • Quinidine and quinine 2

• Diuretics:

  • Thiazide diuretics (particularly common) 1
  • Bumetanide, furosemide, indapamide, triamterene 1

• Anti-arrhythmic drugs:

  • Amiodarone and dronedarone 1

Antimicrobial Agents

• Antibiotics (various classes) 5
• Antifungals (including terbinafine) 5
• Antimalarials 3
• Antitubercular drugs 5

Psychotropic and Neurologic Medications

• Antidepressants:

  • SSRIs: citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline 1
  • Others: clomipramine, imipramine, venlafaxine 1
  • St. John's wort 1

• Antipsychotics: aripiprazole, chlorpromazine, clozapine, flupenthixol, haloperidol, olanzapine, risperidone, thioridazine 1

• Anxiolytics: alprazolam, chlordiazepoxide 1

• Anticonvulsants: carbamazepine 2

• Lithium 2

Other Common Medications

• NSAIDs: ampiroxicam, celecoxib, diclofenac, ibuprofen, indomethacin, ketoprofen, naproxen, piroxicam and others 1, 5, 2
• Lipid-lowering drugs: atorvastatin, pravastatin, simvastatin 1
• Antihistamines: cetirizine, loratadine 6
• Corticosteroids: methylprednisolone 6
• Antidiabetics: chlorpropamide and other sulfonylureas 4, 2
• Penicillamine (particularly strong association) 7, 2
• Gold compounds 2, 3

Newer Medications

• Biologics: TNF antagonists 3
• Immune checkpoint inhibitors: anti-PD-1 antibodies 1, 3

Clinical Presentation

Lichenoid drug reactions typically present as:

• Erythematous papules or plaques resembling lichen planus 1
• Often affecting sun-exposed areas 3
• Can involve mucosal areas with painful ulcerative disease 1
• May appear 2-3 weeks after medication initiation 5

Diagnosis and Management

• Diagnosis is primarily clinical but can be confirmed with skin biopsy showing characteristic band of dense dermal lymphocytic infiltrate with degeneration and vacuolization of the basal membrane 1
• Management involves discontinuation of the suspected medication 5
• Resolution typically occurs within 8-12 weeks after drug withdrawal 5

Important Considerations

• Lichenoid drug reactions can be difficult to differentiate from idiopathic lichen planus 2
• The reaction may be more common in patients aged 20-40 years but can occur at any age 6
• Rechallenge with the suspected medication may confirm the diagnosis but is generally not recommended due to risk of recurrence 2
• Consider alternative medications from different classes when a lichenoid reaction occurs

Understanding which medications can trigger lichenoid reactions is essential for prompt diagnosis and management, as discontinuation of the offending agent is the primary treatment approach.