What are the treatment options for Lichen Planus?

Treatment Options for Lichen Planus

High-potency topical corticosteroids are the first-line treatment for lichen planus, with clobetasol 0.05% or fluocinonide 0.05% gel being the most effective options. 1

Treatment Algorithm Based on Disease Location and Severity

First-Line Treatments

• High-potency topical corticosteroids (clobetasol propionate 0.05% or fluocinonide 0.05% gel) should be applied twice daily to affected areas for 2-3 months as the primary treatment for all forms of lichen planus 1, 2
• For oral lichen planus specifically, gel formulations are preferred over creams/ointments for better mucosal adherence 1
• Topical calcineurin inhibitors, such as tacrolimus 0.1% ointment, can be used as an alternative first-line option when corticosteroids are contraindicated or ineffective 1

Treatment Based on Disease Severity

• For mild to moderate disease: High-potency topical corticosteroids in appropriate formulation for 2-3 months 1
• For moderate to severe disease: Continue topical corticosteroids and consider adding:
  • Oral antihistamines (for pruritus)
  • Short course of oral prednisone
  • Narrow-band UVB phototherapy 1
• For refractory cases: Consider doxycycline with nicotinamide or referral to dermatology for systemic immunomodulators 1

Important Clinical Considerations

Administration and Duration

• Apply a thin layer of clobetasol propionate gel, cream, or ointment to affected areas twice daily 3
• Treatment should be limited to 2 consecutive weeks when using super-high potency corticosteroids, and amounts greater than 50g per week should be avoided 3
• Treat until symptoms improve to Grade 1, then taper over 3 weeks to prevent rebound flares 1
• Occlusive dressings should not be used with clobetasol propionate 3

Monitoring and Follow-up

• Regular follow-up at 3 months is necessary to assess treatment response and monitor for adverse effects 1
• If no improvement is seen within 2 weeks, reassessment of diagnosis may be necessary 3

Potential Side Effects

• Topical corticosteroid side effects include cutaneous atrophy, adrenal suppression, hypopigmentation, and contact sensitivity 4
• Fungal infections (particularly candidiasis) are common during treatment of oral lichen planus and may require concurrent antifungal therapy 5

Special Considerations for Oral Lichen Planus

• Topical therapy is more cost-effective and has fewer side effects than systemic therapy for oral lichen planus 6
• Complete remission rates are similar between topical-only and systemic-followed-by-topical approaches (approximately 69%) 6

Systemic Treatment Options

• Systemic corticosteroids (prednisone) should be reserved for:
  • Acute exacerbations
  • Multiple or widespread lesions
  • Cases unresponsive to topical treatments 5, 7
• For chronic, aggressive lesions resistant to standard treatments, additional therapies may include PUVA, retinoids, or cyclosporin 8

Disease Course

• Cutaneous lichen planus may resolve spontaneously within 1-2 years, though recurrences are common 2
• Mucosal forms (oral, genital) tend to be more persistent and resistant to treatment 2

Common Pitfalls to Avoid

• Failing to obtain a biopsy for atypical presentations, which can lead to misdiagnosis and treatment failure 7
• Using cream/ointment formulations instead of gels for oral mucosal disease 1
• Abrupt discontinuation of corticosteroids, which can lead to rebound flares 1
• Overlooking fungal infections (particularly candidiasis) as a complication of treatment 5