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Lichen planus is a mucocutaneous disease. It is a chronic inflammatory condition with most likely an autoimmune origin. Doctors in primary care have a high chance of encountering lichen planus in their practice. The disease is a common dermatologic issue, and its oral manifestation (oral lichen planus) is among the most frequent mucosal conditions.

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Overview

The first symptom of lichen planus is a characteristic rash. These acute flare-ups may affect the skin, nails, hair, gums, the inside of the cheeks, and the genital area.

The cause of the disease remains hidden. It is most likely a T-cell mediated immunological condition. The responsible antigen, however, is unknown.

Lichen planus is rare in children. It mostly affects middle-aged patients. Women are more likely to experience the condition, with a female to male ratio being 1.5 to 1.

The distribution of the disease is equal among all ethnicities. However, oral lichen planus (OLP) is more common in patients originating from the Indian subcontinent.

Lichen planus is incurable.

Diagnosis – How to recognise a lichen planus rash

The main features of a lichen planus rash are small, slightly-raised, and shiny purple-red papules. They appear in clusters and often display fine white streaks on the surface. The rash usually occurs inside the mouth cavity (OLP), on the penis, around the wrists and ankles, and on nails.

Blisters and scales may form as well.

On the skin, the rash is itchy. On mucosa, it often becomes erosive (ulcerative) and very painful.

With adequate training in general dermatology, doctors should have no trouble identifying lichen planus.

The presence of characteristic LP rash components and previous clinical history is usually enough to diagnose the disease.

No specific laboratory tests exist. In severe cases, however, laboratory testing can rule out other conditions, such as:

• Lupus erythematosus,
• Benign mucous membrane pemphigoid (BMMP), and
• Pemphigus Vulgaris

Who can treat lichen planus?

Lichen planus treatment aims to control the disease and relieve the symptoms. The mild manifestations rarely require treatment.

In many cases, the treatment dictates a multidisciplinary approach. It involves various specialties. These may include:

• Dermatologists
• General practitioners
• Dentists
• Urologists
• Gynaecologists

The consultation in a primary care setting determines the further course of action. The general practitioner should empathically explain to the patient that their illness is chronic and incurable. That the symptoms may disappear and come back again, and that the purpose of treatment is to reduce the flare-ups and alleviate symptoms.

Psychological support referral is helpful in some cases.

Management of lichen planus

Primary care practitioners usually treat mild LP of the skin with steroid creams. The goal is to calm the itchiness and diminish the appearance of the rash.

Moderate LP of the skin requires more potent topical steroids. With proper use, they will calm the itchiness and clear the rash. In such cases, papules become flat and grey or brownish.

They remain different from the surrounding skin for a while.

Prescription topicals, such as tacrolimus, allow long-term use and are helpful in certain areas. These include:

• Face,
• Armpits, and
• Groins

Unlike steroids, these medications do not cause side effects, such as skin thinning.

Severe and widespread LP requires the use of steroid tablets, UVB therapy, or oral medications, such as:

• Acitretin,
• Methotrexate, and
• Hydroxychloroquine

In addition to corticosteroids and medications, oral LP requires the use of anaesthetic and antiseptic mouthwashes and gels.

– Dr Rosmy De Barros

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References

• Berger TG. Lichen planus. JAMA Dermatol. 2015;151(3):356. doi:10.1001/jamadermatol.2014.5522
• Le Cleach L, Chosidow O. Clinical practice. Lichen planus. N Engl J Med. 2012;366(8):723-732. doi:10.1056/NEJMcp1103641
• Puza C, Cardones AR. Concepts and controversies in the treatment of cutaneous lichen planus. G Ital Dermatol Venereol. 2017;152(6):607-614. doi:10.23736/S0392-0488.17.05778-9