Lichen planus: Difference between revisions
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==Background== | |||
*Uncommon disorder of unknown cause, likely T-cell mediated autoimmunity against basal kertinocytes | |||
*Most common in patients aged 30 to 60 years | |||
*HCV association is controversial | |||
*Drug exposure can resemble idiopathic lichen planus | |||
===Affected areas=== | |||
*Skin (cutaneous lichen planus) | |||
*Oral cavity (oral lichen planus) | |||
*Genitalia (penile or vulvar lichen planus) | |||
*Scalp (lichen planopilaris) | |||
*Nails | |||
*Esophagus | |||
==Clinical Features== | |||
===Cutaneous Lichen Planus=== | |||
''Predominantly on ankles and volar surface of wrists'' | |||
*Four “P’s” | |||
**Pruritic | |||
**Purple | |||
**Polygonal | |||
**Papules or plaques | |||
*Wickham’s striae: Fine white lines visible on surface of papules or plaques | |||
*Koebner reaction: Lesions develop in areas of trauma (e.g., scratching) | |||
===Cutaneous variants=== | |||
====Hypertrophic lichen planus==== | |||
*Intensely pruritic, flat-topped plaques | |||
*Common sites are extensor surfaces of lower extremities | |||
====Atrophic lichen planus==== | |||
*Violaceous, round or oval, atrophic plaques | |||
*Common sites are legs | |||
*Often resolution of annular or hypertrophic lesions | |||
====Annular lichen planus==== | |||
*Violaceous plaques with central clearing | |||
*Common sites are penis, scrotum, and intertriginous areas | |||
====Bullous lichen planus==== | |||
*Vesicles or bullae within existing lesions | |||
*Common sites are legs | |||
====Actinic lichen planus (lichen planus tropicus)==== | |||
*Photodistributed eruption of hyperpigmented macules, annular papules, or plaques | |||
*Most common in Africa, Middle East, and India | |||
====Lichen planus pigmentosus==== | |||
*Gray-brown or dark brown macules or patches | |||
*Sun-exposed or flexural areas | |||
*Pruritis minimal or absent | |||
====Inverse lichen planus==== | |||
*Erythematous to violaceous papules and plaques | |||
*Intertriginous sites (e.g., axillae, inguinal creases, inframammary area, limb flexures) | |||
*Hyperpigmentation is common | |||
*Scales and erosions may be present | |||
====Overlap syndromes==== | |||
*Lichen planus pemphigoides | |||
*Lichen planus-lupus erythematosus overlap syndrome | |||
====Other forms of lichen planus==== | |||
*Nail lichen planus [[File:Lehman, 2009 Fig11.tiff|thumb|Lichen planus involving the nails]] | |||
**Varies from minor atrophy to total nail loss | |||
*Lichen planopilaris (follicular lichen planus) | |||
**Keratotic papules that may coalesce into plaques | |||
**Classic site is the scalp | |||
**May be in other body sites (e.g., Graham-Little-Piccardi-Lasseur syndrome) | |||
**Untreated, can result in scarring and permanent alopecia | |||
*Oral lichen planus [[File:Lichen Planus Fig7.tiff|thumb|Lichen planus on the lips and the lateral border of the tongue]] | |||
**Painful, frequent loss of appetite | |||
**May lead to secondary candida infection | |||
*Genital lichen planus | |||
**Involves glans of penis or epithelium of vulva, vestibule, vagina, and mouth | |||
**Often resistant to treatment | |||
*Esophageal lichen planus | |||
**Associated dysphagia or odynophagia | |||
**Concomitant oral, genital, or cutaneous lichen planus | |||
*Otic lichen planus | |||
**Erythema, induration, and stenosis of external auditory canal | |||
**Thickening of TM | |||
**Otorrhea | |||
**Hearing loss | |||
==Differential diagnosis== | |||
The differential diagnosis for lichen planus includes: | |||
*Chronic graft-versus-host disease | |||
*Psoriasis | |||
*Atopic dermatitis | |||
*Lichen simplex chronicus | |||
*Subacute cutaneous lupus erythematosus | |||
*Discoid lupus erythematosus | |||
*Pityriasis rosea | |||
*Secondary syphilis | |||
*Prurigo nodularis | |||
*Paraneoplastic pemphigus/paraneoplastic autoimmune multiorgan syndrome (PAMS) | |||
*Oral leukoplakia | |||
*Oral candidiasis | |||
*Pemphigus vulgaris | |||
*Benign mucous membrane pemphigoid | |||
*Lichenoid drug eruption | |||
**Antimicrobial substances | |||
***Aminosalicylate sodium, ethambutol, griseofulvin, ketoconazole, streptomycin, tetracycline, trovafloxacin, isoniazid | |||
**Antihistamines | |||
***Ranitidine, roxatidine | |||
**Antihypertensives/antiarrhythmics | |||
***ACE-inhibitors (captopril, enalapril), doxazosin, beta blockers (propranolol, labetalol, sotalol), methyldopa, prazosin, nifedipine, quinidine | |||
**Antimalarial drugs | |||
***Chloroquine, hydroxychloroquine, quinine | |||
**Antidepressives/antianxiety drugs/antipsychotics/anticonvulsants | |||
***Amitriptyline, carbamazepine, chlorpromazine, levomepromazine, methopromazine, imipramine, lorazepam, phenytoin | |||
**Diuretics | |||
***Thiazide diuretics (chlorothiazide and hydrochlorothiazide), furosemide, spironolactone | |||
**Antidiabetics | |||
***Sulfonylureas (chlorpropamide, glimepiride, tolazamide, tolbutamide, glyburide) | |||
**Metals | |||
***Gold salts, arsenic, bismuth, mercury, palladium, lithium | |||
**Non-steroidal-antiinflammatory drugs (NSAIDs) | |||
***Acetylsalicylic acid, benoxaprofen, diflunisal, fenclofenac, flurbiprofen, ibuprofen, indomethacin, naproxen, sulindac | |||
**Proton pump inhibitors | |||
***Omeprazole, lansoprazole, pantoprazole | |||
**Lipid lowering drugs | |||
***Pravastatin, simvastatin, gemfibrozil | |||
**TNF-alpha antagonists | |||
***Infliximab, adalimumab, etanercept, lenercept | |||
**Varia | |||
***Allopurinol, bleomycin, cinnarizine, cyanamide, dapsone, hydroxyurea, hepatitis B-vaccine, imatinib, immunoglobulins, interferon alfa, l-thyroxin, levamisole, mesalamine, methycran, penicillamine, procainamide, pyrimethamine, pyrithioxine, quinacrine, sildenafil, sulfasalazine, terbinafine, trihexyphenidyl, ursodeoxycholic acid | |||
==Diagnosis== | |||
Often clinical diagnosis | |||
===Questions to ask=== | |||
*Current medications | |||
*Pruritus | |||
*Oral or genital erosions or pain | |||
*Dysphagia or odynophagia | |||
*Risk factors for HCV | |||
===Physical exam=== | |||
*Expose and examine all cutaneous surfaces | |||
===Workup=== | |||
====Biopsy==== | |||
*Punch biopsy or shave biopsy | |||
*Immunofluorescence studies if bullous lesions present | |||
====Histologic Findings==== | |||
*Pathologic findings seen in lichen planus | |||
**Hyperkeratosis with | |||
**Vacuolization of basal layer with increased melanin | |||
**Hypergranulosis with irregular widening/elongation of rete ridges | |||
**Apoptotic keratinocytes in lower epidermis (Civatte bodies) and papillary dermis (eosinophilic colloid bodies) | |||
**Formation of small clefts with lymphocytic infiltrate at dermal-epidermal junction | |||
====Dermoscopy==== | |||
*Wickham’s striae | |||
====HCV testing==== | |||
*Routine testing controversial | |||
==Managment== | |||
====Cutaneous==== | |||
Self-limiting disease, usually resolves within 8-12 months | |||
*First-line | |||
**[[Topical corticosteroid]] | |||
***High potency (e.g., trunk, extremities) | |||
****0.05% betamethasone dipropionate cream/ointment BID | |||
****0.05% diflorasone diacetate cream/ointment BID | |||
***Mid- or low-potency (e.g., intertriginous areas, facial skin) | |||
**Intralesional corticosteroids (hypertrophic lichen planus) | |||
***2.5 to 10 mg/ml triamcinolone acetonide q4-6 weeks | |||
*Second-line therapy | |||
**For generalized disease or local corticosteroid-refractory disease | |||
***Oral [[glucocorticoids]] | |||
****Optimal dose/duration unknown | |||
****30 to 60 mg qd 4-6 weeks followed by 4-6 week taper | |||
***Phototherapy (e.g, Uultraviolet B, psoralen plus Ultraviolet A) | |||
***Oral acitretin | |||
====Genital==== | |||
*Topical corticosteroids or topical calcineurin inhibitors | |||
====Lichen planopilaris==== | |||
*Topical corticosteroids or intralesional corticosteroids | |||
====Oral==== | |||
*Topical corticosteroids | |||
====Nail==== | |||
*Systemic or intralesional corticosteroids | |||
==Disposition== | |||
*Outpatient treatment | |||
==Prognosis== | |||
====Cutaneous lichen planus==== | |||
*Remits within 1 to 2 years | |||
====Oral, genital, scalp, and nail lichen planus==== | |||
*More persistent and resistant to therapy | |||
*Squamous cell carcinoma risk is unclear (highest risk with erythematous or erosive oral and genital lichen planus) | |||
Monitor for medication adverse effects | |||
==External Links== | |||
==References== | |||
*Goldstein, BG, Goldstein, AO, Mostow, E. Lichen planus. In: UpToDate, Dellavalle, RP, Callen, J (Ed), UpToDate, Waltham, MA, 2017. |
Revision as of 17:20, 17 August 2019
Background
- Uncommon disorder of unknown cause, likely T-cell mediated autoimmunity against basal kertinocytes
- Most common in patients aged 30 to 60 years
- HCV association is controversial
- Drug exposure can resemble idiopathic lichen planus
Affected areas
- Skin (cutaneous lichen planus)
- Oral cavity (oral lichen planus)
- Genitalia (penile or vulvar lichen planus)
- Scalp (lichen planopilaris)
- Nails
- Esophagus
Clinical Features
Cutaneous Lichen Planus
Predominantly on ankles and volar surface of wrists
- Four “P’s”
- Pruritic
- Purple
- Polygonal
- Papules or plaques
- Wickham’s striae: Fine white lines visible on surface of papules or plaques
- Koebner reaction: Lesions develop in areas of trauma (e.g., scratching)
Cutaneous variants
Hypertrophic lichen planus
- Intensely pruritic, flat-topped plaques
- Common sites are extensor surfaces of lower extremities
Atrophic lichen planus
- Violaceous, round or oval, atrophic plaques
- Common sites are legs
- Often resolution of annular or hypertrophic lesions
Annular lichen planus
- Violaceous plaques with central clearing
- Common sites are penis, scrotum, and intertriginous areas
Bullous lichen planus
- Vesicles or bullae within existing lesions
- Common sites are legs
Actinic lichen planus (lichen planus tropicus)
- Photodistributed eruption of hyperpigmented macules, annular papules, or plaques
- Most common in Africa, Middle East, and India
Lichen planus pigmentosus
- Gray-brown or dark brown macules or patches
- Sun-exposed or flexural areas
- Pruritis minimal or absent
Inverse lichen planus
- Erythematous to violaceous papules and plaques
- Intertriginous sites (e.g., axillae, inguinal creases, inframammary area, limb flexures)
- Hyperpigmentation is common
- Scales and erosions may be present
Overlap syndromes
- Lichen planus pemphigoides
- Lichen planus-lupus erythematosus overlap syndrome
Other forms of lichen planus
- Nail lichen planus
- Varies from minor atrophy to total nail loss
- Lichen planopilaris (follicular lichen planus)
- Keratotic papules that may coalesce into plaques
- Classic site is the scalp
- May be in other body sites (e.g., Graham-Little-Piccardi-Lasseur syndrome)
- Untreated, can result in scarring and permanent alopecia
- Oral lichen planus
- Painful, frequent loss of appetite
- May lead to secondary candida infection
- Genital lichen planus
- Involves glans of penis or epithelium of vulva, vestibule, vagina, and mouth
- Often resistant to treatment
- Esophageal lichen planus
- Associated dysphagia or odynophagia
- Concomitant oral, genital, or cutaneous lichen planus
- Otic lichen planus
- Erythema, induration, and stenosis of external auditory canal
- Thickening of TM
- Otorrhea
- Hearing loss
Differential diagnosis
The differential diagnosis for lichen planus includes:
- Chronic graft-versus-host disease
- Psoriasis
- Atopic dermatitis
- Lichen simplex chronicus
- Subacute cutaneous lupus erythematosus
- Discoid lupus erythematosus
- Pityriasis rosea
- Secondary syphilis
- Prurigo nodularis
- Paraneoplastic pemphigus/paraneoplastic autoimmune multiorgan syndrome (PAMS)
- Oral leukoplakia
- Oral candidiasis
- Pemphigus vulgaris
- Benign mucous membrane pemphigoid
- Lichenoid drug eruption
- Antimicrobial substances
- Aminosalicylate sodium, ethambutol, griseofulvin, ketoconazole, streptomycin, tetracycline, trovafloxacin, isoniazid
- Antihistamines
- Ranitidine, roxatidine
- Antihypertensives/antiarrhythmics
- ACE-inhibitors (captopril, enalapril), doxazosin, beta blockers (propranolol, labetalol, sotalol), methyldopa, prazosin, nifedipine, quinidine
- Antimalarial drugs
- Chloroquine, hydroxychloroquine, quinine
- Antidepressives/antianxiety drugs/antipsychotics/anticonvulsants
- Amitriptyline, carbamazepine, chlorpromazine, levomepromazine, methopromazine, imipramine, lorazepam, phenytoin
- Diuretics
- Thiazide diuretics (chlorothiazide and hydrochlorothiazide), furosemide, spironolactone
- Antidiabetics
- Sulfonylureas (chlorpropamide, glimepiride, tolazamide, tolbutamide, glyburide)
- Metals
- Gold salts, arsenic, bismuth, mercury, palladium, lithium
- Non-steroidal-antiinflammatory drugs (NSAIDs)
- Acetylsalicylic acid, benoxaprofen, diflunisal, fenclofenac, flurbiprofen, ibuprofen, indomethacin, naproxen, sulindac
- Proton pump inhibitors
- Omeprazole, lansoprazole, pantoprazole
- Lipid lowering drugs
- Pravastatin, simvastatin, gemfibrozil
- TNF-alpha antagonists
- Infliximab, adalimumab, etanercept, lenercept
- Varia
- Allopurinol, bleomycin, cinnarizine, cyanamide, dapsone, hydroxyurea, hepatitis B-vaccine, imatinib, immunoglobulins, interferon alfa, l-thyroxin, levamisole, mesalamine, methycran, penicillamine, procainamide, pyrimethamine, pyrithioxine, quinacrine, sildenafil, sulfasalazine, terbinafine, trihexyphenidyl, ursodeoxycholic acid
- Antimicrobial substances
Diagnosis
Often clinical diagnosis
Questions to ask
- Current medications
- Pruritus
- Oral or genital erosions or pain
- Dysphagia or odynophagia
- Risk factors for HCV
Physical exam
- Expose and examine all cutaneous surfaces
Workup
Biopsy
- Punch biopsy or shave biopsy
- Immunofluorescence studies if bullous lesions present
Histologic Findings
- Pathologic findings seen in lichen planus
- Hyperkeratosis with
- Vacuolization of basal layer with increased melanin
- Hypergranulosis with irregular widening/elongation of rete ridges
- Apoptotic keratinocytes in lower epidermis (Civatte bodies) and papillary dermis (eosinophilic colloid bodies)
- Formation of small clefts with lymphocytic infiltrate at dermal-epidermal junction
Dermoscopy
- Wickham’s striae
HCV testing
- Routine testing controversial
Managment
Cutaneous
Self-limiting disease, usually resolves within 8-12 months
- First-line
- Topical corticosteroid
- High potency (e.g., trunk, extremities)
- 0.05% betamethasone dipropionate cream/ointment BID
- 0.05% diflorasone diacetate cream/ointment BID
- Mid- or low-potency (e.g., intertriginous areas, facial skin)
- High potency (e.g., trunk, extremities)
- Intralesional corticosteroids (hypertrophic lichen planus)
- 2.5 to 10 mg/ml triamcinolone acetonide q4-6 weeks
- Topical corticosteroid
- Second-line therapy
- For generalized disease or local corticosteroid-refractory disease
- Oral glucocorticoids
- Optimal dose/duration unknown
- 30 to 60 mg qd 4-6 weeks followed by 4-6 week taper
- Phototherapy (e.g, Uultraviolet B, psoralen plus Ultraviolet A)
- Oral acitretin
- Oral glucocorticoids
- For generalized disease or local corticosteroid-refractory disease
Genital
- Topical corticosteroids or topical calcineurin inhibitors
Lichen planopilaris
- Topical corticosteroids or intralesional corticosteroids
Oral
- Topical corticosteroids
Nail
- Systemic or intralesional corticosteroids
Disposition
- Outpatient treatment
Prognosis
Cutaneous lichen planus
- Remits within 1 to 2 years
Oral, genital, scalp, and nail lichen planus
- More persistent and resistant to therapy
- Squamous cell carcinoma risk is unclear (highest risk with erythematous or erosive oral and genital lichen planus)
Monitor for medication adverse effects
External Links
References
- Goldstein, BG, Goldstein, AO, Mostow, E. Lichen planus. In: UpToDate, Dellavalle, RP, Callen, J (Ed), UpToDate, Waltham, MA, 2017.