What is the recommended treatment for lichen planus?

Treatment of Lichen Planus

Start with potent topical corticosteroids as first-line therapy for all forms of lichen planus, escalating to systemic agents only when topical treatment fails or disease is severe and widespread. 1

First-Line Therapy: Topical Corticosteroids

• Apply high-potency topical corticosteroids as the standard initial treatment for symptomatic lichen planus, as they effectively reduce pain and inflammation with minimal side effects. 2
• For oral lichen planus, use potent topical steroids as first-line agents due to their proven efficacy and favorable safety profile compared to systemic options. 2
• Topical corticosteroids are recommended over systemic agents for long-term management because lichen planus is a chronic disorder requiring extended treatment, and topical formulations minimize systemic side effects while providing cost benefits. 2

Common Side Effects to Monitor

• Watch for secondary candidiasis, which commonly develops during topical steroid therapy for oral lichen planus. 2
• Minor side effects may include bad taste, nausea, dry mouth, sore throat, and oral swelling with certain topical steroid formulations. 2

Second-Line and Adjunctive Therapies

• Reserve systemic corticosteroids for acute exacerbations, multiple widespread lesions, or patients unresponsive to topical steroids. 2
• For vulvovaginal lichen planus, 40% of patients may require oral prednisolone either as adjunctive therapy or alone to achieve remission induction, typically achieving symptomatic and objective disease control within a mean of 7.5 weeks. 3

Maintenance Therapy Options

• Use topical tacrolimus (34.3% of patients in one series) in combination with topical corticosteroids for maintenance therapy when initial improvement needs to be sustained. 3
• Consider low-dose weekly methotrexate (8.5% of patients) for maintenance in treatment-refractory cases, as it demonstrates substantial activity in oral lichen planus even in heavily pretreated patients. 4, 3

Therapeutic Ladder for Refractory Disease

For patients who fail initial therapy, follow this sequential escalation approach: 4

1. Start with topical corticosteroids
2. Progress to topical immunomodulators (tacrolimus)
3. Add systemic retinoids if needed
4. Escalate to methotrexate for persistent disease
5. Consider thalidomide for severe refractory cases

• This laddered approach achieves substantial lesion regression even in heavily pretreated and treatment-refractory patients, with best responses observed in previously untreated patients. 4
• Approximately 37% of patients require multimodal therapy to maintain their initial improvement over the long term. 3

Critical Diagnostic Considerations

• Perform biopsy before initiating treatment to confirm diagnosis and exclude squamous cell carcinoma, as this is essential for both lichen planus and lichen sclerosus (which can be confused clinically). 5
• Use both clinical and histopathologic evidence for diagnosis; direct and indirect immunofluorescence techniques can provide additional diagnostic support. 6

Long-Term Monitoring Requirements

• Maintain periodic follow-up due to ongoing controversy about the possible premalignant character of oral lichen planus. 6
• For vulvovaginal lichen planus, long-term symptomatic and objective control is achievable but requires flexible treatment programs and judicious use of oral agents, with mean follow-up demonstrating no progression to VIN or carcinoma when properly managed. 3

Important Pitfall to Avoid

• Do not confuse lichen planus with lichen sclerosus—they are distinct entities with different histopathology, anatomical predilections, and malignancy risks (lichen sclerosus carries a 4-5% risk of squamous cell carcinoma, requiring more aggressive surveillance). 5