What is the treatment for lichen planus?

Treatment of Lichen Planus

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

Initial Treatment Approach

Topical Corticosteroid Regimen

• Apply clobetasol propionate 0.05% ointment once daily for 4 weeks, then alternate days for 4 weeks, followed by twice weekly for 4 weeks 3
• A 30g tube should last approximately 12 weeks when used appropriately 3
• Use the fingertip unit method to ensure proper application amount and minimize side effects 3
• Topical corticosteroids have high-quality evidence supporting their efficacy 2

Adjunctive Measures

• Eliminate all irritants and fragranced products that may exacerbate the condition 3
• Use soap substitutes and barrier preparations alongside topical steroids 3
• For oral lichen planus, avoid hot and spicy foods that trigger symptoms 4

Follow-Up and Maintenance

• Review all patients after the initial 12-week treatment period to assess response 3
• If successful, hyperkeratosis, fissuring, and erosions should resolve 3
• For ongoing active disease, continue clobetasol propionate 0.05% as needed 3
• Most patients with persistent disease require approximately 30-60g of clobetasol propionate annually 3
• Always taper topical steroids gradually rather than stopping abruptly to prevent rebound flares 3

Second-Line Treatment Options

Topical Calcineurin Inhibitors

• Topical tacrolimus is an effective alternative, particularly for vulvovaginal lichen planus 1
• Calcineurin inhibitors have high-quality evidence supporting their use 2

Systemic Corticosteroids

• Consider systemic corticosteroids for severe, widespread lichen planus involving oral, cutaneous, or genital sites 1
• Systemic steroids have moderate quality evidence 2

Treatment for Refractory Cases

Intralesional Corticosteroids

• For steroid-resistant hyperkeratotic areas, consider intralesional triamcinolone 10-20mg after excluding malignancy by biopsy 3, 5

Systemic Immunosuppressants

• Low-dose methotrexate demonstrates substantial activity in oral lichen planus, particularly in treatment-refractory patients 6
• A therapeutic ladder approach progressing from topical corticosteroids through topical immunomodulators, systemic retinoids, methotrexate, and thalidomide can achieve substantial lesion regression even in heavily pretreated patients 6
• Refer to dermatology for systemic therapy with acitretin or oral immunosuppressants when severe lichen planus does not respond to topical treatment 1

Emerging Therapies

• Recent reports describe newer agents including anti-IL17, anti-IL12/23, anti-IL23, PDE4 inhibitors, and JAK inhibitors for refractory oral lichen planus 4
• However, these agents currently have low or very low quality evidence 2

Important Clinical Considerations

Diagnosis Confirmation

• Perform a 4-mm punch biopsy for atypical cases or treatment-resistant disease to confirm diagnosis and exclude malignancy 1, 3
• Biopsy is mandatory before initiating treatment to rule out squamous cell carcinoma 7

Malignancy Risk

• Oral lichen planus is classified as an oral potentially malignant disorder with low but real risk of malignant transformation 4
• Regular monitoring for non-healing lesions is essential 7

Disease Course

• Cutaneous lichen planus may resolve spontaneously within 1-2 years, though recurrences are common 1
• Mucosal lichen planus (oral and genital) tends to be more persistent and resistant to treatment compared to cutaneous disease 1, 4
• Best responses are observed in previously untreated patients 6

Common Pitfalls to Avoid

• Do not discontinue treatment prematurely: ensure a full 12-week course before declaring treatment failure 3
• Do not stop topical steroids abruptly: always taper gradually to prevent rebound 3
• Do not neglect biopsy in treatment-resistant cases: perform biopsy when response is poor to exclude alternative diagnoses or malignancy 3
• Do not fail to educate patients: counsel extensively about the chronic and progressive nature of the disease, particularly for mucosal variants 8

When to Refer to Dermatology

• Lichen planus unresponsive to first-line topical treatments after 12 weeks 3
• Severe, widespread disease requiring systemic therapy 1
• Suspected complications including secondary infection or malignancy 3
• Anogenital lichen planus with anatomical changes requiring surgical intervention 3