What is the 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 lichen planus, with tacrolimus 0.1% ointment as an effective alternative. 1, 2, 3

Initial Management Approach

Cutaneous Lichen Planus

• Apply high-potency topical corticosteroids (clobetasol 0.05%) to affected skin areas twice daily until lesions improve 2, 3
• Continue treatment until symptoms resolve to minimal activity, then taper over 3 weeks to prevent rebound 1
• Expect potential spontaneous resolution within 1-2 years, though recurrences are common 2

Oral Lichen Planus

• Use gel formulations of high-potency corticosteroids (clobetasol 0.05% or fluocinonide 0.05%) for mucosal disease, as these adhere better to oral tissues 1
• Tacrolimus 0.1% ointment is recommended as an equally effective first-line alternative for all grades of oral lichen planus 1
• Oral mucosal disease tends to be more persistent and treatment-resistant compared to cutaneous forms 2, 4
• Biopsy is mandatory before initiating treatment to confirm diagnosis and rule out squamous cell carcinoma, as oral lichen planus is classified as an oral potentially malignant disorder 1, 4

Genital Lichen Planus

• High-potency topical corticosteroids remain first-line therapy for vulvovaginal and penile lesions 2
• Tacrolimus 0.1% ointment appears particularly effective for vulvovaginal lichen planus 2

Second-Line Treatment Options

When topical therapy fails or disease is severe and widespread:

• Systemic corticosteroids (prednisone) should be considered for severe, widespread disease involving oral, cutaneous, or genital sites 1, 2
• Oral antihistamines may provide symptomatic relief of pruritus in moderate to severe cases 1
• Narrow-band UVB phototherapy can be considered if available 1

Refractory Disease Management

For patients not responding to topical and systemic corticosteroids:

• Refer to dermatology for systemic therapy with acitretin (oral retinoid) or oral immunosuppressants 2
• Note that acitretin is expensive and has significant toxicity concerns 2
• Emerging therapies including anti-IL17, anti-IL12/23, anti-IL23, PDE4 inhibitors, and JAK inhibitors show promise for refractory cases, though evidence remains limited 4

Critical Clinical Considerations

Quality of Evidence

• High-quality evidence supports topical steroids and calcineurin inhibitors as first-line therapy 3
• Moderate-quality evidence supports oral steroids for severe disease 3
• Most other treatment modalities have low or very low quality evidence, often based on small studies or anecdotal reports 3

Malignancy Risk

• Regular follow-up is essential for oral lichen planus due to its classification as an oral potentially malignant disorder, albeit with low transformation risk 4
• Monitor for non-healing lesions that may indicate malignant transformation 1

Common Pitfalls to Avoid

• Do not skip biopsy confirmation—clinical diagnosis alone is insufficient, especially for atypical presentations 2
• Avoid abrupt discontinuation of topical corticosteroids; taper gradually to prevent rebound 1
• Do not treat mucosal disease with the same formulations used for skin—gel formulations are superior for oral lesions 1
• Recognize that mucosal lichen planus requires longer treatment duration and may never fully resolve 2, 4

Treatment Algorithm Summary

1. Confirm diagnosis with biopsy (mandatory) 1, 2
2. Start high-potency topical corticosteroids (clobetasol 0.05%) or tacrolimus 0.1% for mild-moderate disease 1, 2, 3
3. Add systemic corticosteroids for severe or widespread involvement 1, 2
4. Consider oral antihistamines for symptomatic pruritus relief 1
5. Refer to dermatology for systemic immunosuppressants or retinoids if refractory 2
6. Schedule regular follow-ups to monitor treatment response and assess for malignant transformation, particularly in oral disease 1, 4