What is the treatment for lichen planus of the skin?

Treatment of Cutaneous Lichen Planus

High-potency topical corticosteroids, specifically clobetasol propionate 0.05%, applied once daily for 2-3 months with gradual tapering, are the definitive first-line treatment for lichen planus of the skin. 1, 2

First-Line Treatment Protocol

Initial Treatment Phase

• Apply clobetasol propionate 0.05% ointment once daily for 2-3 months to cutaneous lesions (ointment formulations work better than gels for skin lesions) 1
• Continue treatment until hyperkeratosis, ecchymoses, fissuring, and erosions resolve—note that atrophy and color change may persist even after successful treatment 1
• A 30g tube should last approximately 12 weeks for the initial treatment phase 1

Tapering Protocol

• After the initial 2-3 month treatment period, gradually taper to alternate-day application for 4 weeks 1
• Then reduce to twice-weekly applications for maintenance to prevent rebound flares 1, 2
• The American Academy of Dermatology emphasizes that abrupt discontinuation must be avoided, as this leads to rebound flares 2

Alternative First-Line Option

• Tacrolimus 0.1% ointment can be used when corticosteroids are contraindicated or have failed 2
• This is particularly useful for patients concerned about long-term steroid side effects 3

Treatment for Severe or Refractory Disease

• For severe, widespread cutaneous disease, systemic corticosteroids (prednisone 15-30 mg for 3-5 days) should be considered for acute flares 2, 3
• Referral to dermatology for systemic immunomodulators (methotrexate, hydroxychloroquine, cyclosporine, azathioprine, or mycophenolate mofetil) is appropriate for cases unresponsive to topical treatment 4, 3
• For hypertrophic/verrucous lichen planus specifically, combination therapy with topical steroids in occlusion plus trichloroacetic acid 50% peeling weekly may be effective 5

Adjunctive Measures

• Patients should use soap substitutes and avoid all irritant and fragranced products that may exacerbate the condition 1
• Oral antihistamines can be added for moderate to severe pruritus 2

Monitoring and Follow-Up

• Schedule follow-up at 3 months to assess treatment response, ensure proper medication use, and monitor for adverse effects 1, 2
• If response is satisfactory, conduct a final assessment at 6 months before discharge to primary care 2

Critical Pitfalls to Avoid

• Never abruptly discontinue topical corticosteroids—always taper gradually over 3 weeks to prevent rebound flares 2
• Monitor for potential side effects including cutaneous atrophy, adrenal suppression, hypopigmentation, and contact sensitivity 1, 2
• Instruct patients to wash hands thoroughly after application to avoid spreading medication to sensitive areas like eyes 2
• Do not use gel formulations for cutaneous disease—ointments are superior for skin lesions 1

Expected Outcomes

• Cutaneous lichen planus may resolve spontaneously within 1-2 years, although recurrences are common 3
• Treatment focuses on symptom control and preventing complications rather than cure 3