Lichen Planus

WHAT IS LICHEN PLANUS?

Lichen Planus (LP) (Fig 1) is an inflammatory disease that can affects the skin and/or mouth (oral), or both. It may also affect the genital skin. Skin LP affects men and women equally, but oral LP affects women twice as often as men. LP occurs most frequently in middle-aged adults. The cause of LP is not known. While there are many theories to explain LP, most dermatologists believe it can be classified as an autoimmune disease. This means that white blood cells which usually fight germs begin to attack the normal parts of the skin, mucous membranes, hair, and nails. There are cases of lichen planus-type rashes which occur as allergic reactions to medications for high blood pressure, heart disease, and arthritis. Identifying and stopping the drug helps clear up the condition within a few weeks. An association is noted between LP and hepatitis C virus infection, chronic active hepatitis, and primary biliary cirrhosis Hepatitis should be considered in patients with widespread or unusual presentations of LP. Onset or exacerbation of LP has been linked to stressful events.

LICHEN PLANUS OF THE SKIN

LP of the skin is characterized by reddish-purple, flat-topped bumps that may be very itchy. Some may have a white lacy appearance called Wickham's Striae (Fig. 2). They can be anywhere on the body, but seem to favor the inside of the wrists and ankles. The disease can also occur on the lower back, neck, legs, genitals, and in rare cases, the scalp and nails. LP on the legs is usually much darker in appearance. There may be thick patches (hypertrophic LP) especially on the shins. Blisters are rare except in special cases called bullous LP. While the typical appearance of LP makes the disease somewhat easy to identify, a skin biopsy may be needed to confirm the diagnosis.

LP of the skin usually causes few problems and needs no treatment. If there is severe itching there is help. Many cases of LP go away within two years which is comforting to patients in Jacksonville, Ponte Vedra Beach and Fleming Island. As it heals, LP often leaves a dark brown discoloration on the skin. Like the bumps themselves, these stains may eventually fade with time without treatment. About one out of five people will have a second attack of LP. Variations in LP include the following:

Hypertrophic LP: These extremely pruritic lesions are most often found on the extensor surfaces of the lower extremities, especially around the ankles. Hypertrophic lesions are often chronic; residual pigmentation and scarring can occur when the lesions eventually clear.

Atrophic LP: Atrophic LP is characterized by a few lesions, which are often the resolution of annular or hypertrophic lesions.

Erosive LP: These lesions are found on the mucosal surfaces and evolve from sites of previous LP involvement.

Follicular LP: Lichen planopilaris is characterized by keratotic papules that may coalesce into plaques. This condition is more common in women than in men, and ungual and erosive mucosal involvement is more likely to be present. A scarring alopecia may result.

Annular LP: LP papules that are purely annular are rare. Annular lesions with an atrophic center can be found on the buccal mucosa and the male genitalia.

Linear LP: Isolated linear lesions may form a zosteriform lesion, or they may develop as a Köbner effect.

Vesicular and bullous LP: Most commonly, these lesions develop on the lower limbs or in the mouth from preexisting LP lesions. A rare condition, lichen planus pemphigoides, is a combination of both LP and bullous pemphigoid.

Actinic LP: Subtropic or actinic LP occurs in regions, such as Africa, the Middle East, and India. This mildly pruritic eruption usually spares the nails, the scalp, the mucous membranes, and covered areas. Lesions are characterized by nummular patches with a hypopigmented zone surrounding a hyperpigmented center.

LP pigmentosus: This is a rare variant of LP but can be more common in persons with darker-pigmented skin, such as Latinos or Asians. It usually appears on face and neck. Some believe it is similar to or the same as erythema dyschromicum perstans (ie, ashy dermatosis).

LP pemphigoides: This is a rare form of LP. Blisters subsequently develop on LP lesions. Clinically, histopathologically and immunopathologically, it has features of LP and bullous pemphigoid, it but carries a better prognosis than pemphigoid.

TREATMENT OF LICHEN PLANUS

There is no known cure for LP but treatment is often effective in relieving itching and in improving the appearance of the rash until it goes away. Since every case of LP is different, no one treatment is perfect. The two most common treatments include the use of topical corticosteroid creams, ointments, or other anti-inflammatory drugs, and antihistamines taken by mouth. More severe cases of LP may require stronger medications such as cortisone taken internally or a specific form of ultraviolet light treatment called PUVA. Discuss any potential drug side effects with your dermatologist.

As with other skin disorders, following your dermatologist's advice is the best approach for dealing with LP. Since new areas of LP can form in the damaged skin, try to avoid injury.

LICHEN PLANUS OF THE MOUTH

LP of the mouth most (Fig 3) commonly occurs inside of the cheeks, but can affect the tongue, lips, and gums. Oral LP is more difficult to treat and typically lasts longer than LP on the skin. Fortunately, many cases of LP of the mouth cause minimal problems.

Oral LP typically appears as patches of fine white lines and dots which usually do not cause problems. Dentists often find them during routine check-ups. More severe forms of oral LP can cause painful sores and ulcers in the mouth. Your dermatologist may have to make sure that the sores are not caused by yeast or an infection and are not canker sores. A biopsy of affected tissue may be needed to confirm a diagnosis. Sometimes, the biopsy tissue must be studied by a special technique and blood tests may be needed to rule out other oral diseases.

There have been cases of lichen planus-like allergic reactions to dental materials but they are very rare. Patch testing may be used to pinpoint the allergy; removing dental material is recommended.

TREATMENT FOR LP OF THE MOUTH

There is no known cure for oral LP although there are many treatments that eliminate the pain of sores. When the disease causes no pain or burning, treatment may not be needed. More severe forms of LP - those with pain, burning, redness, blisters, sores, and ulcers - can be treated with a variety of medications, both applied to the sores (topical) and taken by mouth (oral). As with any disease of the lining of the mouth, LP can lead to poor dental hygiene and gum disease. Careful daily oral hygiene is very important. Schedule regular visits to the dentist for examinations and cleanings at least twice a year.

ARE YOU AT RISK FOR ORAL CANCER IF YOU HAVE ORAL LP?

Patients with oral LP may be at a slightly increased risk of developing oral cancer. Because of this increased risk, it is wise to discontinue the use of alcohol and tobacco products which also increase the risk. Regular visits to the dermatologist - every six to twelve months - for an oral cancer screening is recommended.

OTHER THINGS TO CONSIDER

Spicy foods, citrus juices, tomato products, caffeinated drinks like coffee and cola, and crispy foods like toast and corn chips can aggravate LP especially if there are open sores in the mouth.

LICHEN PLANUS OF THE GENITALS

LP of the genitals is less common in men than women. About one in five women have vulvar or vaginal LP. There may be no problems if it is mild, but red areas or open sores may cause pain, especially with sexual intercourse and needs treatment.

NAIL INVOLVEMENT

Nail changes have been observed in LP. The majority of nail changes result from damage to the nail matrix, or nail root. Only a few fingernails or toenails are usually involved, but occasionally all are affected. Nail changes can occur with or without skin involvement.

Nail changes associated with LP include longitudinal ridging and grooving, splitting, nail thinning, and nail loss. In severe cases, the nail may be temporarily or permanently destroyed.

SCALP INVOLVEMENT

LP can affect hairy areas such as the scalp in rare cases. This is called lichen planopilaris, and can lead to redness, irritation, and in some cases, permanent hair loss.

SUMMARY

LP may be unpleasant and difficult to treat, but it is a stable condition. The severity and distribution of the disease rarely changes after the first few months. Although there is no cure for LP, ADAS providers will usually be able to develop a treatment plan to control your symptoms. For more information on Lichen Planus or to set up a consultation, click here or call 904-285-7546. Thank you and we look forward to helping you.

For more information on lichen_planus or to set up a consultation, click here or call 904-285-7546. Thank you and we look forward to helping you.