What are the clinical presentation and treatment guidelines for a patient with lichen planus?

Lichen Planus: Clinical Presentation and Treatment

Clinical Presentation

Lichen planus presents as the "6 P's": planar (flat-topped), purple, polygonal, pruritic papules and plaques, typically affecting flexor surfaces of wrists, forearms, and legs, with characteristic lacy white Wickham striae overlying the lesions. 1

Cutaneous Features

• Acute onset of flat-topped, purple, polygonal papules and plaques on flexor surfaces 1
• Wickham striae: lacy, reticular white lines covering lesions 1
• Pruritus is common and may be severe enough to disturb sleep 2
• Koebnerization (lesions at sites of trauma) occurs frequently 2

Oral Manifestations

• Affects 1-2% of the general population, predominantly women over age 40 3
• Multiple clinical patterns: reticular (most common), erosive, erythematous, plaque-like, papular, and bullous forms 4
• Erosive form is the predominant type in 40% of patients at initial presentation 5
• Isolated gingival involvement occurs in 8.6% of patients 5
• Symptoms present in the majority of patients regardless of clinical form 5
• Bilateral buccal mucosa is the most common site, but can affect tongue, gingiva, lips, and palate 4

Genital Involvement

• Occurs in 19% of women and 4.6% of men with oral lichen planus 6
• Dyspareunia occurs with erosions, fissures, or introital narrowing 2
• May cause architectural changes including loss of labia minora, clitoral hood sealing, and introital stenosis 2

Other Sites

• Scalp involvement (lichen planopilaris) in approximately 1% of patients 6
• Nail involvement in approximately 2% of patients 6
• Esophageal involvement in approximately 1% of patients 6
• Extraoral manifestations occur in approximately 16% of patients with oral disease 6

Exacerbating Factors

• Stress is a common precipitating factor 5
• Certain foods may trigger flares 5
• Dental procedures can exacerbate disease 5
• Poor oral hygiene worsens symptoms 5

Diagnostic Approach

Perform a 4-mm punch biopsy for atypical presentations or when clinical diagnosis is uncertain, as classic cases may be diagnosed clinically based on characteristic morphology and distribution. 1

• Biopsy is mandatory when there is suspicion of malignancy (persistent hyperkeratosis, erosion, erythema, or new warty/papular lesions) 2
• Direct and indirect immunofluorescence can aid diagnosis in unclear cases 3
• Document baseline architectural changes using diagrams or photographs 2

Treatment Guidelines

First-Line Treatment: High-Potency Topical Corticosteroids

Clobetasol propionate 0.05% is the first-line treatment for all forms of lichen planus, with formulation selection based on anatomic location: gel for oral lesions and cream/ointment for cutaneous disease. 7

For Cutaneous Lichen Planus:

• Apply clobetasol propionate 0.05% ointment or cream twice daily for 2-3 months 7, 1
• After initial treatment, taper gradually: alternate days for 4 weeks, then twice weekly for maintenance 8
• A 30g tube should last approximately 12 weeks for the initial treatment phase 8

For Oral Lichen Planus:

• Apply clobetasol propionate 0.05% gel or fluocinonide 0.05% gel to dried oral mucosa twice daily for 2-3 months 7
• Gel formulations are mandatory for oral disease—never use cream or ointment formulations intraorally as they lack appropriate mucosal adherence 7
• For localized lesions, clobetasol 0.05% can be mixed in 50% Orabase and applied twice weekly 9

For Genital Lichen Planus:

• Apply clobetasol propionate 0.05% ointment once daily for 1 month, then alternate days for 1 month, then twice weekly for 1 month 2
• Combine with soap substitutes and barrier preparations 2

Critical Medication Instructions:

• Never abruptly discontinue topical corticosteroids—taper gradually over 3 weeks to prevent rebound flares 7
• Educate patients on proper application amount, site, and safe use 2
• Advise aggressive hand washing after application to avoid spreading to sensitive areas (eyes) and partner exposure 2
• Avoid all irritant and fragranced products 2, 8

Adjunctive Therapies for Symptom Control

• Oral antihistamines for moderate to severe pruritus 7
• Compound benzocaine gel for severe pain 7
• 0.1% chlorhexidine gargling solution to reduce inflammation and prevent secondary infection in oral disease 7
• Short course of oral prednisone 15-30 mg for 3-5 days for acute severe flares 7

Second-Line Treatment: Topical Calcineurin Inhibitors

Tacrolimus 0.1% ointment is an effective steroid-sparing alternative when corticosteroids are contraindicated or ineffective. 7, 1

• Particularly effective for vulvovaginal lichen planus 1
• Apply twice daily to affected areas 9

Treatment for Refractory Disease

When topical corticosteroids fail despite good compliance:

• Intralesional triamcinolone acetonide injections for localized resistant lesions 9
• Narrow-band UVB phototherapy for moderate to severe widespread disease 9
• Doxycycline with nicotinamide for refractory cases 9
• Systemic corticosteroids for severe, widespread disease involving oral, cutaneous, or genital sites 1
• Referral to dermatology for systemic immunomodulators (acitretin or oral immunosuppressants) for severe disease unresponsive to topical treatment 1, 9

Potential Side Effects of Topical Corticosteroids:

• Cutaneous atrophy 2, 8
• Adrenal suppression 2, 8
• Hypopigmentation 2, 8
• Contact sensitivity (burning, itching, dryness, flaking, maceration) 2

Follow-Up Protocol

Schedule follow-up at 3 months to assess treatment response, ensure proper medication use, and monitor for adverse effects. 7, 8

• If response is satisfactory, conduct final assessment at 6 months before discharge to primary care 7
• Continue treatment until hyperkeratosis, ecchymoses, fissuring, and erosions resolve (note that atrophy and color change may persist) 8
• Maintain with twice-weekly applications after initial improvement 8

Malignant Potential and Long-Term Monitoring

Oral squamous cell carcinoma develops in approximately 0.8% of patients with oral lichen planus, necessitating periodic follow-up to detect malignant transformation. 5

• Malignancy typically develops at sites previously diagnosed as erosive or erythematous lichen planus 5
• Perform biopsy for any persistent area of hyperkeratosis, erosion, erythema, or new warty/papular lesions 2
• Periodic follow-up is mandatory due to low but real risk of malignant transformation 3, 5
• Routine screening for hepatitis C and liver abnormalities is not warranted in American patients (unlike Italian and Japanese populations) 5

Evaluation of Treatment Failure

When topical corticosteroids appear ineffective, systematically evaluate:

• Compliance with medication regimen 7
• Diagnostic accuracy (consider repeat biopsy) 7
• Secondary sensory problems 7
• Mechanical problems 7

Prognosis

• 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 chronic, persistent, and resistant to treatment 1, 4
• Women typically experience a more chronic course than men 4