Saturday, January 01, 2011
Lichen planus (LP) may be self-limited or chronic and presents
as localized or generalized disease, usually with mild to severe
pruritus. Occasionally patients have ulcerative, painful mucosal
lesions. The aim of therapy is to control symptoms and suppress
mucocutaneous lesions, and therefore must be appropriate to the
extent and severity of the disease.
Localized Lichen Planus
- Apply superpotent fluorinated topical steroid ointment or cream
once or twice daily until the lesions flatten and disappear.
- Prescribe an antihistamine to control pruritus. Before bed,
diphenhydramine 50-75 mg or hydroxyzine 25-50 mg may be taken.
- Reduce the superpotent fluorinated topical steroid to a
medium-potency agent (e.g., triamcinolone acetonide 0.1% ointment
or cream once or twice daily), and apply as necessary to control
- Reduce antihistamines to levels necessary to control
- Occlude superpotent steroids with plastic wrap daily. Occlusive
dressings may be applied for 4-6 hours prior to bed, or overnight,
if tolerated. When lesions flatten (within 7-14 days), discontinue
occlusion and continue topical steroids alone as above.
- Inject lesions with triamcinolone acetonide 5-10 mg/ml, and
repeat in 2-3 weeks. One to three treatments per lesion are usually
Generalized Lichen Planus
While treatment with systemic steroids leads to rapid
improvement, generalized LP almost invariably relapses as the
steroids are tapered. Therefore, systemic steroids should only be
used when absolutely necessary.
- Topical corticosteroids applied under an occlusive vinyl suit
for 8-12 hours daily may be effective in reducing pruritus.
- Photochemotherapy (PUVA) may be helpful. Treat twice per week
and expect a response in 3-6 weeks.
- Narrowband ultraviolet B (UVB) may also be effective at 3 times
- Acetretin 0.5-1 mg/kg/day or isotretinoin 20-60 mg daily,
alone, or when added to phototherapy may be effective.
- Hydroxychloroquine 250 mg twice daily for several months.
Most patients do not require aggressive treatment beyond topical
steroids, retinoids or phototherapy. In severe cases, consider the
- Thalidomide 100 to 200 mg daily.
- Mycophenolate mofeteil 2-3 g daily.
- Cyclosporine 3-5 mg/kg/day.
Follicular and/or Nail Lichen Planus
Treat as if disease were generalized. The scarring hair and nail
loss is permanent, and an aggressive approach is reasonable in the
absence of medical contraindications. A reasonable order of
attempted treatments would be as follows:
- Topical and intralesional steroids.
- Hydroxychloroquine 250 mg twice daily for 3 months.
- Cyclosporine 3-5 mg/kg/day for a 3-month trial, or
mycophenolate mofeteil 2-3 g per day for a 3-month trial.
Hypertrophic Lichen Planus
- Intralesional steroids (triamcinolone acetonide 10 mg/ml).
Repeat weekly or biweekly if necessary.
- Application of superpotent topical steroids (e.g., clobetasol
propionate) with or without occlusion with plastic wrap. Occlude
lesions for 4-10 hours.
- Acetretin 0.5-1 mg/kg/day or isotretinoin 20-60 mg daily.
Phototherapy with PUVA or narrow band UVB may be added to oral
In very unusual cases aggressive therapy as for severe
generalized LP above.
Oral and Genital (Vulvar) Lichen Planus
Most nonulcerative cases are asymptomatic and do not require
therapy. Ulcerative disease is often symptomatic, and should be
treated. Forty percent of women with erosive oral LP also have
erosive vulvar lesions, but do not identify them to their
dermatologist unless specifically queried. Lesions are frequently
misdiagnosed as genital lichen sclerosus. Erosive genital lesions
are treated identically to oral lesions.
- Apply fluorinated steroids in a dental paste (Kenalog in
Orabase) as frequently as possible. For disease of the gingivae, a
dental tray may enhance therapy.
- Inject lesions with triamcinolone acetonide 5-10 mg/mL. Lesions
may be injected every 2-3 weeks, up to 3-4 times if necessary.
- Tacrolimus ointment 0.1% applied twice daily.
- Oral and vulval erosive disease is frequently complicated by
secondary infection with Candida albicans. Topical
anticandidal therapy, or oral fluconazole 100 mg daily for one
week, then 150 mg every week, will control this complication and
make the management of the mucosal disease much easier.
- If the patient responds to treatment, continue as required.
Patients with ulcerative disease must be followed for the
development of oral or genital squamous cell carcinoma.
- In patients who have failed first-line therapy,
hydroxychloroquine 250 mg twice daily for 3 months.
- Cyclosporine 3-5 mg/kg/day, or mycophenolate mofeteil 2-3
- Thalidomide 100-200 mg per day for a 3-month trial.
- Eximer laser 308 nm 100 mJ/cm2 weekly to the oral
lesions for up to 2 months may be beneficial and avoid the need for
- LP may be drug induced. Common culprits include thiazides,
gold, quinidine, and nonsteroidal antiinflammatory drugs.
Discontinue these agents. In the case of gold-induced LP,
resolution may take months. Dental mercurial amalgams may be
associated with an oral erosive lichenoid eruption.
- Thalidomide is a potent teratogen and should not be used in
women of childbearing potential. It may also cause neuropathy and
- Erosive LP of the oral mucosa, genitalia, and, rarely, of the
skin may be complicated by the development of squamous cell