Treatment of Lichen Planus
High-potency topical corticosteroids are the first-line treatment for all forms of lichen planus, including cutaneous, oral, and genital lesions. 1
First-Line Treatment Options
- Apply clobetasol propionate 0.05% or fluocinonide 0.05% gel to affected areas twice daily for 2-3 months, then taper gradually to avoid rebound flares 1, 2
- For oral lichen planus, gel formulations are preferred over creams/ointments for mucosal disease 1, 2
- For localized lesions, clobetasol 0.05% ointment can be mixed in 50% Orabase and applied twice weekly 1
- Topical calcineurin inhibitors (tacrolimus 0.1% ointment) are effective alternatives when corticosteroids are contraindicated or ineffective 1, 2
Treatment Based on Disease Location
Oral Lichen Planus
- Apply clobetasol 0.05% or fluocinonide 0.05% gel to dried mucosa twice daily 2
- Treat until symptoms improve to Grade 1, then taper over 3 weeks 2
- For refractory cases, consider doxycycline with nicotinamide 1, 2
Cutaneous Lichen Planus
- High-potency topical corticosteroids applied twice daily to affected areas 1, 3
- Onset is usually acute, affecting the flexor surfaces of the wrists, forearms, and legs 3
- Advise patients to avoid irritants and fragranced products that may exacerbate the condition 1
Nail Lichen Planus
- Intralesional triamcinolone acetonide is considered first-line therapy for nail involvement 4
- Early treatment is essential to prevent permanent nail destruction 4
Treatment for Moderate to Severe Disease
- For widespread involvement, consider a short course of oral prednisone 1, 3
- Narrow-band UVB phototherapy is an option for moderate to severe disease 1
- Add oral antihistamines for pruritus control 1, 2
- For refractory cases, intralesional triamcinolone acetonide injections may be effective 1
- Referral to dermatology for systemic immunomodulators (acitretin, methotrexate, cyclosporine) may be necessary for severe cases unresponsive to topical treatments 1, 5, 6
Important Clinical Considerations
- Biopsy is necessary to confirm diagnosis in atypical cases and to rule out malignancy 1
- Regular follow-up at 3 months is necessary to assess treatment response 1
- Lichen planus may resolve spontaneously within one to two years, although recurrences are common 3
- Mucosal forms tend to be more persistent and resistant to treatment 3
- Potential side effects of topical steroids include cutaneous atrophy, adrenal suppression, hypopigmentation, and contact sensitivity 7
- Periodic follow-up is recommended due to the controversial potential premalignant character of oral lichen planus 8
Treatment Pitfalls to Avoid
- Failure to taper corticosteroids gradually can lead to rebound flares 1, 2
- Using cream/ointment formulations instead of gels for oral mucosal disease reduces effectiveness 1, 2
- Delaying treatment of nail lichen planus may lead to permanent destruction with functional consequences 4
- Tetracycline alone (without nicotinamide) is not recommended based on recent evidence 6