What is the recommended treatment for lichen planus?

Treatment of Lichen Planus

High-potency topical corticosteroids, specifically clobetasol propionate 0.05% or fluocinonide 0.05%, are the first-line treatment for all forms of lichen planus, including cutaneous, oral, and genital lesions. 1, 2

First-Line Treatment Approach

Cutaneous Lichen Planus

• Apply clobetasol propionate 0.05% ointment twice daily to affected skin areas for 2-3 months, then taper gradually to prevent rebound flares 1
• Intralesional triamcinolone acetonide injections are effective for localized, thick plaques that don't respond to topical therapy 1, 3
• Oral antihistamines should be added for pruritus control in moderate to severe disease 1

Oral Lichen Planus

• Use clobetasol propionate 0.05% or fluocinonide 0.05% gel (not cream or ointment) applied to dried mucosa twice daily for 2-3 months 1, 2
• Gel formulations are specifically preferred over creams/ointments for mucosal disease because they adhere better to wet surfaces 1, 2
• For localized oral lesions, mix clobetasol 0.05% ointment in 50% Orabase and apply twice weekly 1
• Treat until symptoms improve to Grade 1, then taper over 3 weeks to avoid rebound 2

Genital Lichen Planus

• Apply clobetasol propionate 0.05% twice daily for 2-3 months with gradual dose tapering 1
• Patients must wash hands thoroughly after application to avoid spreading medication to eyes or exposing partners 4
• Address psychosexual issues when genital disease affects quality of life 1
• In males with disease limited to foreskin and glans, circumcision may be beneficial 1

Alternative First-Line Options

• Topical tacrolimus 0.1% ointment is an effective alternative when corticosteroids are contraindicated or ineffective 1, 2
• This is particularly useful for patients concerned about long-term steroid side effects such as cutaneous atrophy, adrenal suppression, or hypopigmentation 4

Treatment Escalation for Moderate to Severe Disease

When topical therapy alone is insufficient:

1. Add a short course of oral prednisone for widespread cutaneous involvement 1
2. Consider narrow-band UVB phototherapy for moderate to severe disease 1, 2
3. For refractory cases, try doxycycline with nicotinamide 1, 2
4. Refer to dermatology for systemic immunomodulators (methotrexate, hydroxychloroquine, cyclosporine, azathioprine, or mycophenolate mofetil) if the above measures fail 1, 2, 5

Low-dose methotrexate has demonstrated substantial activity in treatment-refractory oral lichen planus with limited toxic effects 6

Special Considerations for Nail Lichen Planus

• Topical treatment has poor short-term efficacy for nail involvement 7
• Intralesional and intramuscular triamcinolone acetonide should be considered first-line therapies for nail lichen planus 7
• Oral retinoids are second-line choices for nail disease 7
• Prompt treatment is essential even in mild nail cases to prevent permanent destruction with severe functional consequences 7

Critical Clinical Pitfalls to Avoid

• Never use cream or ointment formulations instead of gels for oral mucosal disease - they don't adhere properly 2
• Always taper corticosteroids gradually - abrupt discontinuation leads to rebound flares 1, 2
• Biopsy is necessary to confirm diagnosis in atypical cases and rule out malignancy 1
• Regular follow-up at 3 months is mandatory to assess treatment response and monitor for adverse effects 1, 4
• Oral lichen planus has controversial premalignant potential, requiring periodic long-term surveillance 8
• Advise patients to avoid irritants and fragranced products that may exacerbate the condition 1

Monitoring and Follow-Up

• Assess response at 3-month intervals 1, 4
• Monitor for corticosteroid side effects including cutaneous atrophy, adrenal suppression, hypopigmentation, and contact sensitivity 4
• Use potent steroids cautiously in pediatric patients 4
• Surgical management may be needed for cases with anatomical changes or strictures 1