What is the best treatment for lichen planus?

Treatment of Lichen Planus

High-potency topical corticosteroids, specifically clobetasol propionate 0.05%, are the definitive first-line treatment for all forms of lichen planus, with gel formulations mandatory for oral disease and cream/ointment for cutaneous lesions. 1

Initial Treatment Protocol

Cutaneous Lichen Planus

• Apply clobetasol propionate 0.05% cream or ointment twice daily to affected skin areas for 2-3 months, then taper gradually over subsequent weeks 1, 2
• The structured tapering regimen should follow: once daily for 4 weeks, then alternate nights for 4 weeks, followed by twice weekly for 4 weeks 1
• A 30-gram tube should last approximately 12 weeks when used appropriately 3

Oral Lichen Planus

• Apply clobetasol 0.05% gel or fluocinonide 0.05% gel to dried oral mucosa twice daily for 2-3 months 1
• Gel formulations are mandatory—never use cream or ointment for oral disease, as only gels provide appropriate mucosal adherence 1
• Continue treatment until symptoms improve to Grade 1, then taper gradually over 3 weeks to prevent rebound flares 1
• Alternative formulation: clobetasol 0.05% ointment mixed in 50% Orabase applied twice weekly for localized lesions 1

Genital Lichen Planus

• Apply clobetasol propionate 0.05% cream/ointment using the same tapering protocol as cutaneous disease 1
• Topical tacrolimus 0.1% ointment is an effective alternative for vulvovaginal disease when corticosteroids fail 2

Adjunctive Symptomatic Management

• Apply compound benzocaine gel topically for severe pain control 1
• Use 0.1% chlorhexidine gargling solution to reduce inflammation and prevent secondary infection in oral disease 1
• Prescribe oral antihistamines for moderate to severe pruritus 1
• Consider a short course of oral prednisone 15-30 mg for 3-5 days for acute severe flares 1

Second-Line Systemic Therapy

When to Escalate

• Reserve systemic corticosteroids for severe, widespread disease involving oral, cutaneous, or genital sites simultaneously 2, 4
• Topical therapy alone is more cost-effective and has fewer side effects than systemic therapy followed by topical therapy 5

Systemic Options for Refractory Disease

• Oral acitretin (30 mg daily for 8 weeks) is first-line systemic therapy for cutaneous disease not responding to topical treatment 6
• Systemic corticosteroids are second-line systemic options 6
• Refer to dermatology for oral immunosuppressants if severe disease fails topical and systemic corticosteroid therapy 2

Nail Lichen Planus (Specialized Management)

• Intralesional triamcinolone acetonide is first-line therapy for isolated nail disease 7
• Intramuscular triamcinolone acetonide is also first-line 7
• Oral retinoids are second-line choices for nail involvement 7
• Topical treatment has poor short-term efficacy for nail disease and should not be used as monotherapy 7

Critical Pitfalls to Avoid

• Never abruptly discontinue topical corticosteroids—always taper gradually over 3 weeks to prevent severe rebound flares 1
• Never use cream or ointment formulations for oral mucosal disease—this is a common error that leads to treatment failure 1
• Do not prescribe systemic corticosteroids as first-line therapy for localized disease, as topical therapy achieves similar remission rates (approximately 69%) with significantly fewer side effects 5
• Instruct patients to wash hands thoroughly after application to avoid spreading medication to eyes or other sensitive areas 1, 3

Monitoring and Follow-Up

• Schedule initial follow-up at 3 months to assess treatment response, ensure proper medication use, and monitor for adverse effects 1, 3
• If response is satisfactory, conduct a final assessment at 6 months before discharge to primary care 1
• Monitor for potential side effects including cutaneous atrophy, adrenal suppression, hypopigmentation, and contact sensitivity 1, 3
• Instruct patients to report any persistent ulceration or new growth, as oral lichen planus carries a small risk of malignant transformation to squamous cell carcinoma 1

Expected Outcomes

• Lichen planus may resolve spontaneously within 1-2 years, although recurrences are common 2
• Mucosal disease tends to be more persistent and resistant to treatment than cutaneous disease 2
• Complete remission of signs and symptoms occurs in approximately 69% of patients treated with topical corticosteroids alone 5
• While hyperkeratosis and symptoms improve with treatment, complete resolution of all skin changes (such as atrophy and color change) may not occur 8, 3