What are the treatment options for lichen planus?

Treatment Options for Lichen Planus

High-potency topical corticosteroids are the first-line treatment for all forms of lichen planus, including cutaneous, oral, and genital lesions. 1, 2

Treatment Based on Location and Severity

Oral Lichen Planus

• Apply clobetasol propionate 0.05% or fluocinonide 0.05% gel to dried mucosa twice daily for 2-3 months, then taper gradually to avoid rebound flares 1
• Gel formulations are preferred over creams/ointments for mucosal disease 1, 3
• Topical calcineurin inhibitors (tacrolimus 0.1% ointment) are effective alternatives when corticosteroids are contraindicated or ineffective 1, 4
• For localized lesions, clobetasol 0.05% ointment can be mixed in 50% Orabase and applied twice weekly 3

Cutaneous Lichen Planus

• High-potency topical corticosteroids are first-line therapy 2
• For widespread cutaneous disease, systemic corticosteroids should be considered 2, 5
• Acitretin (30 mg daily for 8 weeks) is an effective first-line systemic therapy for widespread cutaneous disease 5

Erosive/Severe Lichen Planus

• For moderate to severe disease, consider adding:
  • Oral antihistamines for pruritus control 3
  • Short course of oral prednisone for widespread involvement 1
  • Narrow-band UVB phototherapy 1
• For refractory cases:
  • Intralesional triamcinolone acetonide injections 3
  • Doxycycline with nicotinamide 1
  • Referral to dermatology for systemic immunomodulators 1

Genital Lichen Planus

• Topical corticosteroids are first-line therapy 2
• Tacrolimus appears to be an effective treatment for vulvovaginal lichen planus 2

Treatment Algorithm for Refractory Disease

1. First-line: High-potency topical corticosteroids (clobetasol 0.05% or fluocinonide 0.05%) 1, 2
2. Second-line: Topical calcineurin inhibitors (tacrolimus 0.1%) 1, 3
3. Third-line: Systemic corticosteroids for severe, widespread disease 2, 5
4. Fourth-line: Systemic therapies in order of preference:
   • Acitretin (most evidence) 5
   • Methotrexate and hydroxychloroquine 6
   • Cyclosporine, azathioprine, or mycophenolate mofetil 6, 4

Important Clinical Considerations

• Biopsy is necessary to confirm diagnosis in atypical cases and to rule out malignancy 3, 2
• Regular follow-up at 3 months is necessary to assess treatment response 3
• Lichen planus may resolve spontaneously within 1-2 years, although recurrences are common 2
• Mucosal forms tend to be more persistent and resistant to treatment 2, 4
• Advise patients to avoid irritants and fragranced products that may exacerbate the condition 3

Special Considerations for Lichen Sclerosus

• For lichen sclerosus, which is distinct from lichen planus but sometimes confused with it, clobetasol propionate 0.05% twice daily for 2-3 months with gradual dose tapering is recommended 7
• In males with genital lichen sclerosus, circumcision may be beneficial for disease limited to the foreskin and glans 7
• Surgical management may be needed for cases with anatomical changes or strictures 7