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Therapeutic Strategies

Lichen Planus

Timothy Berger Bruce Wintroub

Saturday, January 01, 2011

Overview

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

First Steps

  1. Apply superpotent fluorinated topical steroid ointment or cream once or twice daily until the lesions flatten and disappear.
  2. Prescribe an antihistamine to control pruritus. Before bed, diphenhydramine 50-75 mg or hydroxyzine 25-50 mg may be taken.

Subsequent Steps

  1. 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 lesions.
  2. Reduce antihistamines to levels necessary to control pruritus.

Alternative Steps

  1. 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.
  2. Inject lesions with triamcinolone acetonide 5-10 mg/ml, and repeat in 2-3 weeks. One to three treatments per lesion are usually adequate.

Generalized Lichen Planus

First Steps

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.

  1. Topical corticosteroids applied under an occlusive vinyl suit for 8-12 hours daily may be effective in reducing pruritus.

Alternative Steps

  1. Photochemotherapy (PUVA) may be helpful. Treat twice per week and expect a response in 3-6 weeks.
  2. Narrowband ultraviolet B (UVB) may also be effective at 3 times per week.
  3. Acetretin 0.5-1 mg/kg/day or isotretinoin 20-60 mg daily, alone, or when added to phototherapy may be effective.
  4. Hydroxychloroquine 250 mg twice daily for several months.

Subsequent Steps

Most patients do not require aggressive treatment beyond topical steroids, retinoids or phototherapy. In severe cases, consider the following:

  1. Thalidomide 100 to 200 mg daily.
  2. Mycophenolate mofeteil 2-3 g daily.
  3. 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:

  1. Topical and intralesional steroids.
  2. Hydroxychloroquine 250 mg twice daily for 3 months.
  3. 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

First Steps

  1. Intralesional steroids (triamcinolone acetonide 10 mg/ml). Repeat weekly or biweekly if necessary.
  2. Application of superpotent topical steroids (e.g., clobetasol propionate) with or without occlusion with plastic wrap. Occlude lesions for 4-10 hours.

Alternative Steps

  1. 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 retinoid treatment.

Subsequent Steps

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.

First Steps

  1. 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.
  2. Inject lesions with triamcinolone acetonide 5-10 mg/mL. Lesions may be injected every 2-3 weeks, up to 3-4 times if necessary.
  3. Tacrolimus ointment 0.1% applied twice daily.
  4. 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.

Subsequent Steps

  1. 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.
  2. In patients who have failed first-line therapy, hydroxychloroquine 250 mg twice daily for 3 months.
  3. Cyclosporine 3-5 mg/kg/day, or mycophenolate mofeteil 2-3 g/day.
  4. Thalidomide 100-200 mg per day for a 3-month trial.
  5. 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 systemic therapies.

Pitfalls

  1. 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.
  2. Thalidomide is a potent teratogen and should not be used in women of childbearing potential. It may also cause neuropathy and venous thrombosis.
  3. Erosive LP of the oral mucosa, genitalia, and, rarely, of the skin may be complicated by the development of squamous cell carcinoma.

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