How to manage hyperpigmentation (increased skin pigmentation) due to lichen planus treatment?

Management of Hyperpigmentation Due to Lichen Planus

For post-inflammatory hyperpigmentation from lichen planus, topical tacrolimus 0.1% ointment is the preferred treatment, as topical corticosteroids—while effective for active disease—do not improve established dyschromia and may worsen pigmentation. 1

Understanding the Clinical Context

Post-inflammatory hyperpigmentation (PIH) in lichen planus represents a distinct therapeutic challenge from active inflammatory disease. The hyperpigmentation results from deep dermal pigmentary incontinence, making it particularly treatment-refractory, especially in darker skin types. 2

First-Line Treatment Approach

For Residual Hyperpigmentation After Active Disease Resolution

• Topical tacrolimus 0.1% ointment should be applied twice daily to hyperpigmented areas, as this has demonstrated efficacy specifically for lichen planus pigmentosus and post-inflammatory dyschromia. 1

• Discontinue topical corticosteroids once active inflammation resolves, as they do not improve established hyperpigmentation and are ineffective for this indication. 1

• Strict photoprotection with broad-spectrum sunscreen is essential, as UV exposure worsens pigmentation and prevents improvement. 2

Important Distinction: Active vs Inactive Disease

If you are treating active lichen planus (with violaceous papules, plaques, or pruritus):

• High-potency topical corticosteroids (clobetasol 0.05% or fluocinonide 0.05%) remain first-line for 2-3 months until symptoms improve to Grade 1, followed by gradual tapering over 3 weeks. 3, 4, 5

• For oral mucosal involvement, use gel formulations specifically (not creams or ointments). 4, 5

• Once active disease is controlled, transition to tacrolimus for residual hyperpigmentation. 1

Second-Line Options for Refractory Hyperpigmentation

Systemic Therapy for Extensive or Resistant Cases

• Low-dose oral isotretinoin (20 mg/day) for 6 months has shown moderate to good improvement in 55.7-77.5% of patients with lichen planus pigmentosus, particularly effective in early disease (≤5 years duration) with limited body surface area involvement. 6

• Disease stabilization typically occurs by 4-6 weeks, with pruritus subsiding within 9-14 days in responsive patients. 6

Advanced Procedural Options

• Modified phenol peels (Croton oil-free phenol combination) performed every 3 weeks for six sessions achieved moderate to excellent improvement (≥25% pigment reduction) in 76% of patients with treatment-refractory lichen planus pigmentosus. 2

• This approach requires thorough skin priming, stringent sun protection, and post-peel adjuvant topicals to maintain effects for up to one year. 2

• Dermoscopic monitoring shows lightening of background color and reduction in density/intensity of pigmented structures. 2

Critical Pitfalls to Avoid

• Never continue topical corticosteroids for established hyperpigmentation—they are ineffective for dyschromia and should only be used during active inflammatory phases. 1

• Avoid friction in intertriginous areas, as mechanical trauma can precipitate or worsen lichen planus pigmentosus inversus. 1

• Remove potential triggers including topical exposures (almond oil, henna, paraphenyldiamine, mustard oil) and evaluate for associated conditions (hypothyroidism, diabetes mellitus, hyperlipidemia). 1

• Narrow-band UVB phototherapy should be used cautiously due to koebnerization risk, though it can be effective for widespread disease when combined with other modalities. 3, 7

Treatment Algorithm Based on Disease Extent and Duration

For localized hyperpigmentation (<3 body areas):

• Start with topical tacrolimus 0.1% ointment twice daily plus strict photoprotection. 1
• If no improvement after 3 months, consider modified phenol peels. 2

For extensive hyperpigmentation or disease duration ≤5 years:

• Consider low-dose oral isotretinoin (20 mg/day) for 6 months as it shows better outcomes in early, limited disease. 6

For treatment-refractory cases:

• Referral to dermatology for modified phenol peels or consideration of systemic immunomodulators (methotrexate, acitretin, hydroxychloroquine) in consultation with appropriate specialists. 3, 7

Monitoring and Follow-Up

• Assess response at 3-month intervals using photographic documentation and patient-reported outcomes. 2

• For isotretinoin therapy, monitor for standard retinoid side effects and evaluate disease stabilization by 4-6 weeks. 6

• Maintain long-term photoprotection even after improvement, as recurrence is common without continued sun avoidance. 2