Lichen Planus

What is Lichen Planus?

Lichen planus (LP) is a condition that causes inflammation of the skin and the lining of the body’s cavities, like the mouth and nasal passages. Its cause is still unknown. The main symptoms are itchy, purple bumps and patches mostly seen on the wrists, lower back and ankles. On these lesions, a network of white lines termed ‘Wickham striae’ can appear. This is especially visible in the mouth where it might also cause sore areas.

LP can sometimes be triggered by medications, resulting in a version known as drug-induced lichen planus or lichenoid drug eruption. This version usually occurs where the skin has been exposed to sunlight and can look quite similar to regular LP.

The course of LP can differ greatly between individuals. For most people, the skin symptoms will disappear on their own within 1 to 2 years from first appearing. But, LP can come back and often leaves a darker pigment on the skin. Oral LP, affecting the mouth, is a long-lasting condition and it’s unclear whether it will go away over time. Drug-induced LP generally gets better once the medication causing it is discontinued.

What Causes Lichen Planus?

Lichen planus is a disease that arises mysteriously, with doctors not completely sure what causes it. However, it’s thought to be an autoimmune disease – this is where the body’s immune system, which usually fights off germs, starts attacking healthy parts of the body.

Most doctors think that lichen planus happens because of a response to outside triggers like a virus, medication, or substances that cause allergies. These triggers can change substances found in the skin’s outer layer, which can make the body’s own protective cells, called CD8+ T cells, attack the skin’s cells.

Lichen planus has been connected to various triggers, but one that stands out is the hepatitis C virus. Researchers found that people with lichen planus are 5 times more likely to test positive for this virus compared to the public. Conversely, those who do have the Hepatitis C virus are 2.5 to 4.5 times more likely to develop lichen planus.

A type of lichen planus that affects the mouth, called oral lichen planus, has been linked to allergies to various metals found in dental fillings like mercury, copper, and gold. Removing these metals has cleared up the skin condition for some.

A vast array of drugs are known to be associated with lichen planus, but a reoccurrence of the skin condition because of these drugs is rare. Common drugs linked to this condition include antimalarial drugs, certain high blood pressure medications, water pills, pain relievers, beta-blockers, medications for inflammatory diseases, and gold treatments (used for certain arthritis types).

Risk Factors and Frequency for Lichen Planus

Cutaneous LP, a skin condition, affects approximately 0.2% to 1% of adults worldwide. A more common condition, Oral LP, is seen in about 1% to 4% of people. Overall, more women than men suffer from these conditions, typically between the ages of 30 and 60. It’s very uncommon for children to have these conditions as they make up less than 5% of all LP patients. Although anyone can get LP, some studies show that African-Americans, and those of Indian and Arabian descent, may be more likely to get it. About 10% of close relatives of a person with LP might also develop these conditions.

Cutaneous LP affects about 0.2% to 1% of adults globally.
Oral LP, which is more common, affects about 1% to 4% of the population.
These conditions affect more women than men, typically those aged 30 to 60.
Children rarely get these conditions, as they represent less than 5% of all LP patients.
While LP can affect anyone, studies show it may be more common in African-Americans, and those of Indian and Arabian descent.
First-degree relatives of patients with LP have a 10% chance of developing the conditions.

Signs and Symptoms of Lichen Planus

Lichen planus is a skin condition that shows different types of spots or lesions. The most common ones look like itchy, purplish, polygon-shaped flat bumps. They can appear as a few spots or a wide area of skin with shiny surfaces covered in fine white lines. The spots can also appear on different parts of the body like wrists, hands, lower back, ankles, and shins. When they heal, they often leave a grayish-brown colored skin due to melanin deposits in the dermis.

Notably, lichen planus can present differently in some cases. These include:

The hypertrophic variant, often found on the shins and ankles, which consists of dense reddish or brownish spots and plaques.
The ulcerative subtype found on the soles of the feet or between the toes. These spots are painful, and may cause difficulties in walking.
Bullous lichen planus, common on legs, presents as small to large clear or pale-yellow filled blisters.
Lichen planus pemphigoids may involve blisters development on top of typical lichen planus spots as well as on normal skin.
Lichen planus pigmentosus may lead to colored nodular or papular lesions.
Inverse lichen planus, similar to inverse psoriasis, mostly appears in skin folds (like armpits, groins), and loses its typical appearance.

Mucosal lichen planus, affecting more than half of the patients, typically attacks the mouth but can also affect lips, esophagus, glans penis, vulva, or vagina. There are six different types of oral lichen planus and they have different presentations, from white, lacy lines on the mouth to painful erosive spots. If lichen planus affects the nails, it can thin the nail plate and cause longitudinal lines. Continued presence of the disease can lead to loss of the nail plate.

Lichen planopilaris (LPP), a subtype of lichen planus, shows up in the hair-bearing areas like the scalp. It can cause red bumps and macules leading to aggressive hair loss due to scarring.

Lastly, certain medications can cause a lichenoid drug eruption which typically appears in sun-exposed areas, is symmetric, and is more generalized in distribution.

Testing for Lichen Planus

In the clinic, a tool called a dermoscope can be used to look at the skin in great detail. This can often reveal Wickham striae, which are a network of white lines with red dots along the sides. This is a common sign of the illness.

If you have oral lesions, or sores, near dental fillings, your doctor might do a patch test. This test can show if you’re allergic to any of the metals used in the filling.

The most accurate way to identify LP, or lichen planus, a type of skin rash, is through a biopsy. This is where a small piece of the skin or sore is removed and studied under a microscope. This reveals certain characteristics that can confirm if it’s LP. In some cases, your doctor might also use a test called direct immunofluorescence. This involves applying a special dye to the sample which glows under a specific type of light, making it easier to distinguish between LP and another condition called lupus erythematosus (LE), which can often appear similar.

Treatment Options for Lichen Planus

Cutaneous Lichen Planus, a condition that affects the skin causing itchiness and red or purple bumps, often goes away on its own within 1 to 2 years. The goal of treatment is mainly to help manage symptoms like itchiness and speed up the healing process. If your condition is limited, creams with high-strength steroids may be applied to affected areas twice daily for 2 to 4 weeks. If there’s little to no improvement, steroid injections into the affected areas might be considered.

In cases where Lichen Planus affects a larger part of your body, oral steroids may be prescribed. If this doesn’t help, other treatments like metronidazole, sulfasalazine, isotretinoin, acitretin, light therapy, other topical medications, or methotrexate might be considered. If the condition still doesn’t improve, drugs like trimethoprim-sulfamethoxazole, griseofulvin, antimalarials, tetracyclines, or low-molecular-weight heparin might be considered as well.

Oral Lichen Planus, which affects the mouth, can sometimes clear up on its own within 5 years. However, in many cases, it persists and relapses even after successful treatment. So, treatment is usually focused on managing symptoms, such as painful mouth sores, and making it easier for the patient to eat normally.

If you don’t have symptoms, you might not need treatment. If you do have symptoms, avoiding spicy or acidic foods as well as alcohol and tobacco may help, as these can make symptoms worse. Treatment often involves using a high-strength steroid cream in the mouth three times daily until symptoms improve. If symptoms do not improve after six weeks, further treatments could be considered. These might include oral steroids or other topical medications, and in some cases, drugs like cyclosporine, azathioprine, mycophenolate mofetil, or methotrexate.

It’s important to consider whether any medications you’re already taking could be contributing to Lichen Planus. If your doctor suspects this, they might recommend discontinuing that medication. If stopping the medication leads to your Lichen Planus gradually disappearing, it will confirm that the drug was the cause, although it can take some time for your skin to fully heal.

When dealing with Lichen Planus (LP), it’s important to first identify potential causes, as this condition may be a response to various factors such as viruses, medications, or contact allergens. Understanding these underlying causes helps in properly diagnosing this condition.

Additionally, there are a number of conditions that may present symptoms similar to LP including:

Lupus Erythematosus (LE)
Erythema dyschromicum perstans
Psoriasis
Secondary syphilis
Pityriasis rosea
Lichen nitidus
Graft versus host disease
Keratosis lichenoides chronica

In the cases of hypertrophic LP, it may resemble lichen simplex chronicus, while vulvar LP can be difficult to distinguish from lichen sclerosis.

Distinguishing between LP and Lupus Erythematosus can be particularly challenging when there are only lesions on the scalp or inside the mouth. In these cases, a biopsy with Direct Immunofluorescence (DIF) could be useful. In some situations, both LP and LE can occur together, a fact that some reports link to the use of antimalarial drugs in the treatment of Lupus Erythematosus.

What to expect with Lichen Planus

Cutaneous LP, a skin condition, usually gets better on its own within one to two years. However, it’s quite common for it to leave behind darkened areas on the skin. Oral LP, which affects the mouth, may also improve on its own, typically within five years. Despite this, it’s more likely to be a long-term condition that comes and goes over time.

When there is hair loss due to LPP (a specific type of LP), it is unfortunately permanent. If your LP has been triggered by a medication, the skin lesions can take a while to clear up, even after you’ve stopped taking the drug.

Frequently asked questions

Lichen planus is a condition that causes inflammation of the skin and the lining of the body's cavities, such as the mouth and nasal passages. It is characterized by itchy, purple bumps and patches on the skin, often accompanied by white lines called 'Wickham striae'.

Cutaneous LP affects about 0.2% to 1% of adults globally.

Signs and symptoms of Lichen Planus include: - Itchy, purplish, polygon-shaped flat bumps that can appear as a few spots or a wide area of skin with shiny surfaces covered in fine white lines. - Spots can appear on different parts of the body like wrists, hands, lower back, ankles, and shins. - When the spots heal, they often leave a grayish-brown colored skin due to melanin deposits in the dermis. - Different variants of Lichen Planus can present with specific characteristics: - Hypertrophic variant: Dense reddish or brownish spots and plaques, often found on the shins and ankles. - Ulcerative subtype: Painful spots found on the soles of the feet or between the toes, causing difficulties in walking. - Bullous lichen planus: Small to large clear or pale-yellow filled blisters, common on legs. - Lichen planus pemphigoids: Blisters development on top of typical lichen planus spots as well as on normal skin. - Lichen planus pigmentosus: Colored nodular or papular lesions. - Inverse lichen planus: Similar to inverse psoriasis, mostly appears in skin folds (like armpits, groins), and loses its typical appearance. - Mucosal lichen planus: Typically attacks the mouth but can also affect lips, esophagus, glans penis, vulva, or vagina. It has different types with varying presentations, from white, lacy lines on the mouth to painful erosive spots. - Nail involvement: Lichen planus can thin the nail plate and cause longitudinal lines. Continued presence of the disease can lead to loss of the nail plate. - Lichen planopilaris (LPP): Shows up in the hair-bearing areas like the scalp, causing red bumps and macules leading to aggressive hair loss due to scarring. - Lichenoid drug eruption: Certain medications can cause a lichenoid drug eruption, which typically appears in sun-exposed areas, is symmetric, and is more generalized in distribution.

Lichen planus is thought to be an autoimmune disease that can be triggered by outside factors such as viruses, medications, or substances that cause allergies. It can also be associated with the hepatitis C virus and allergies to certain metals found in dental fillings.

The other conditions that a doctor needs to rule out when diagnosing Lichen Planus are: - Lupus Erythematosus (LE) - Erythema dyschromicum perstans - Psoriasis - Secondary syphilis - Pityriasis rosea - Lichen nitidus - Graft versus host disease - Keratosis lichenoides chronica - Lichen simplex chronicus (in the case of hypertrophic LP) - Lichen sclerosis (in the case of vulvar LP)

The types of tests that may be ordered to properly diagnose Lichen Planus include: 1. Dermoscopy: This tool can be used to examine the skin in detail and look for Wickham striae, which are characteristic white lines with red dots along the sides. 2. Patch test: If there are oral lesions near dental fillings, a patch test may be done to check for allergies to the metals used in the fillings. 3. Biopsy: A small piece of the skin or sore may be removed and studied under a microscope to confirm the presence of Lichen Planus. 4. Direct immunofluorescence: This test involves applying a special dye to the sample, which can help distinguish between Lichen Planus and another condition called lupus erythematosus. These tests can help in accurately diagnosing Lichen Planus and differentiating it from other similar conditions.

Lichen Planus can be treated in various ways depending on the severity and location of the condition. For cutaneous Lichen Planus, creams with high-strength steroids may be applied to affected areas, and if there is little improvement, steroid injections may be considered. In cases where Lichen Planus affects a larger part of the body, oral steroids or other medications like metronidazole, sulfasalazine, isotretinoin, acitretin, light therapy, or methotrexate may be prescribed. For oral Lichen Planus, treatment focuses on managing symptoms such as painful mouth sores, and options include using a high-strength steroid cream in the mouth, oral steroids, or other topical medications. It is also important to consider whether any medications the patient is already taking could be contributing to Lichen Planus, and discontinuing those medications may be recommended.

When treating Lichen Planus, there can be potential side effects depending on the treatment method used. Some possible side effects include: - Creams with high-strength steroids: Potential side effects may include thinning of the skin, skin discoloration, and increased risk of infection. - Steroid injections: Possible side effects can include pain at the injection site, skin discoloration, and thinning of the skin. - Oral steroids: Side effects may include weight gain, increased appetite, mood changes, high blood pressure, and increased risk of infection. - Other medications like metronidazole, sulfasalazine, isotretinoin, acitretin, methotrexate, trimethoprim-sulfamethoxazole, griseofulvin, antimalarials, tetracyclines, and low-molecular-weight heparin can also have their own potential side effects. It's important to discuss potential side effects with a healthcare professional before starting any treatment for Lichen Planus.

The prognosis for Lichen Planus (LP) varies depending on the type and location of the condition: - Cutaneous LP, a skin condition, usually improves on its own within 1 to 2 years, but may leave behind darkened areas on the skin. - Oral LP, which affects the mouth, may improve on its own within 5 years, but it is more likely to be a long-term condition that comes and goes over time. - Hair loss due to LPP (a specific type of LP) is unfortunately permanent. - If LP is triggered by medication, the skin lesions can take a while to clear up, even after stopping the drug.

Dermatologist.

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