Lichen planus: Difference between revisions
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==Background== | ==Background== | ||
*Uncommon disorder of unknown cause | *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 | *Drug exposure can resemble idiopathic lichen planus | ||
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''Predominantly on ankles and volar surface of wrists'' | ''Predominantly on ankles and volar surface of wrists'' | ||
*Four “P’s” | *Four “P’s” | ||
**Pruritic | **[[Pruritus|Pruritic]] | ||
**Purple | **Purple | ||
**Polygonal | **Polygonal | ||
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====Hypertrophic lichen planus==== | ====Hypertrophic lichen planus==== | ||
*Intensely pruritic, flat-topped plaques | *Intensely pruritic, flat-topped plaques | ||
*Common sites are | *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==== | ====Annular lichen planus==== | ||
*Violaceous plaques with central clearing | *Violaceous plaques with central clearing | ||
*Common sites are penis, scrotum, and intertriginous areas | *Common sites are penis, scrotum, and intertriginous areas | ||
====Bullous lichen planus==== | ====Bullous lichen planus==== | ||
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====Actinic lichen planus (lichen planus tropicus)==== | ====Actinic lichen planus (lichen planus tropicus)==== | ||
*Photodistributed eruption of hyperpigmented macules, annular papules, or plaques | *Photodistributed eruption of hyperpigmented macules, annular papules, or plaques | ||
*Most common in Middle East, India | *Most common in Africa, Middle East, and India | ||
====Lichen planus pigmentosus==== | ====Lichen planus pigmentosus==== | ||
*Gray-brown or dark brown macules or patches | *Gray-brown or dark brown macules or patches | ||
*Sun-exposed or flexural areas | *Sun-exposed or flexural areas | ||
* | *Pruritus minimal or absent | ||
====Inverse lichen planus==== | ====Inverse lichen planus==== | ||
*Erythematous to violaceous papules and plaques | *Erythematous to violaceous papules and plaques | ||
*Intertriginous sites (e.g., axillae, inguinal creases, inframammary area, limb flexures) | *Intertriginous sites (e.g., axillae, inguinal creases, inframammary area, limb flexures) | ||
*Hyperpigmentation is common | *Hyperpigmentation is common | ||
Scales and erosions may be present | *Scales and erosions may be present | ||
====Overlap syndromes==== | ====Overlap syndromes==== | ||
*Lichen planus pemphigoides | *Lichen planus pemphigoides | ||
*Lichen planus-lupus erythematosus overlap syndrome | *Lichen planus-lupus erythematosus overlap syndrome | ||
====Other forms of lichen planus==== | ====Other forms of lichen planus==== | ||
*Nail lichen planus | *Nail lichen planus | ||
**Varies from minor atrophy to total nail loss | **Varies from minor atrophy to total nail loss | ||
*Lichen planopilaris | *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 | **Untreated, can result in scarring and permanent alopecia | ||
*Oral lichen planus | *Oral lichen planus | ||
**Painful, frequent loss of appetite | **Painful, frequent loss of appetite | ||
**May lead to secondary candida infection | **May lead to secondary candida infection | ||
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==Differential diagnosis== | ==Differential diagnosis== | ||
The differential diagnosis for lichen planus includes: | The differential diagnosis for lichen planus includes: | ||
*Chronic [[graft-versus-host disease]] | |||
*[[Psoriasis]] | |||
*[[Atopic dermatitis]] | |||
*Chronic graft-versus-host disease | |||
*Psoriasis | |||
*Atopic dermatitis | |||
*Lichen simplex chronicus | *Lichen simplex chronicus | ||
*Subacute cutaneous lupus erythematosus | *Subacute cutaneous or discoid [[lupus erythematosus]] | ||
* | *[[Pityriasis rosea]] | ||
*Secondary [[syphilis]] | |||
*Secondary syphilis | |||
*Prurigo nodularis | *Prurigo nodularis | ||
*Paraneoplastic pemphigus/paraneoplastic autoimmune multiorgan syndrome (PAMS) | *[[Paraneoplastic]] pemphigus/paraneoplastic autoimmune multiorgan syndrome (PAMS) | ||
*Oral leukoplakia | *Oral leukoplakia | ||
*Oral candidiasis | *Oral [[candidiasis]] | ||
*Pemphigus vulgaris | *[[Pemphigus vulgaris]], benign mucous membrane pemphigoid | ||
*Lichenoid [[drug eruption]] | |||
**Antimicrobials: aminosalicylate sodium, ethambutol, griseofulvin, ketoconazole, streptomycin, tetracycline, trovafloxacin, isoniazid | |||
**Antihistamines: ranitidine, roxatidine | |||
**Antihypertensives/antiarrhythmics: ACE-inhibitors, doxazosin, beta blockers, methyldopa, prazosin, nifedipine, quinidine | |||
**Antimalarial drugs: chloroquine, hydroxychloroquine, quinine | |||
**Antidepressants/anxiolytics/antipsychotics/AEDs: amitriptyline, carbamazepine, chlorpromazine, levomepromazine, methoprazine, imipramine, lorazepam, phenytoin | |||
**Diuretics: thiazide diuretics, furosemide, spironolactone | |||
**Antidiabetics: sulfonylureas | |||
**Metals: gold salts, arsenic, bismuth, mercury, palladium, lithium | |||
**NSAIDs | |||
**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 | |||
{{Plaques DDX}} | |||
==Diagnosis== | ==Diagnosis== | ||
* | *Clinical diagnosis | ||
*Workup outside of ED may include: | |||
* | **Punch biopsy or shave biopsy | ||
* | **Immunofluorescence studies if bullous lesions present | ||
* | **Routine HCV testing controversial | ||
*Immunofluorescence studies if bullous lesions present | |||
* | |||
*Routine testing controversial | |||
== | ==Management== | ||
===Cutaneous=== | |||
*Self-limiting disease, usually resolves within 8-12 months | |||
*First-line | *First-line | ||
**Topical corticosteroid | **[[Topical corticosteroid]] | ||
***High potency (e.g., trunk, extremities) | ***High potency (e.g., trunk, extremities) | ||
****0.05% betamethasone dipropionate cream/ointment BID | ****0.05% [[betamethasone]] dipropionate cream/ointment BID | ||
****0.05% diflorasone diacetate cream/ointment BID | ****0.05% diflorasone diacetate cream/ointment BID | ||
***Mid- or low-potency (e.g., intertriginous areas, facial skin) | ***Mid- or low-potency (e.g., intertriginous areas, facial skin) | ||
**Intralesional corticosteroids (hypertrophic lichen planus) | **Intralesional corticosteroids (hypertrophic lichen planus) | ||
***2.5 to 10 mg/ml triamcinolone acetonide q4-6 weeks | ***2.5 to 10 mg/ml [[triamcinolone acetonide]] q4-6 weeks | ||
*Second-line therapy | *Second-line therapy | ||
**For generalized disease or local corticosteroid-refractory disease | **For generalized disease or local corticosteroid-refractory disease | ||
***Oral glucocorticoids | ***Oral [[glucocorticoids]] | ||
****Optimal dose/duration unknown | ****Optimal dose/duration unknown | ||
****30 to 60 mg qd 4-6 weeks followed by 4-6 week taper | ****30 to 60 mg qd 4-6 weeks followed by 4-6 week taper | ||
***Phototherapy (e.g, | ***Phototherapy (e.g, Ultraviolet B, psoralen plus Ultraviolet A) | ||
***Oral acitretin | ***Oral acitretin | ||
====Genital | |||
====Genital==== | |||
*Topical corticosteroids or topical calcineurin inhibitors | *Topical corticosteroids or topical calcineurin inhibitors | ||
====Lichen planopilaris==== | ====Lichen planopilaris==== | ||
*Topical corticosteroids or intralesional corticosteroids | *Topical corticosteroids or intralesional corticosteroids | ||
====Oral | |||
====Oral==== | |||
*Topical corticosteroids | *Topical corticosteroids | ||
====Nail | |||
====Nail==== | |||
*Systemic or intralesional corticosteroids | *Systemic or intralesional corticosteroids | ||
==Disposition== | ==Disposition== | ||
*Outpatient treatment | |||
==Prognosis== | ==Prognosis== | ||
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*More persistent and resistant to therapy | *More persistent and resistant to therapy | ||
*Squamous cell carcinoma risk is unclear (highest risk with erythematous or erosive oral and genital lichen planus) | *Squamous cell carcinoma risk is unclear (highest risk with erythematous or erosive oral and genital lichen planus) | ||
Monitor for medication adverse effects | |||
==See Also== | |||
==External Links== | ==External Links== | ||
==References== | ==References== | ||
*Goldstein, BG, Goldstein, AO, Mostow, E. Lichen planus. In: UpToDate, Dellavalle, RP, Callen, J (Ed), UpToDate, Waltham, MA, 2017. | |||
[[Category:Dermatology]] |
Latest revision as of 21:06, 29 March 2023
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
- Pruritus 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 or 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
- Antimicrobials: aminosalicylate sodium, ethambutol, griseofulvin, ketoconazole, streptomycin, tetracycline, trovafloxacin, isoniazid
- Antihistamines: ranitidine, roxatidine
- Antihypertensives/antiarrhythmics: ACE-inhibitors, doxazosin, beta blockers, methyldopa, prazosin, nifedipine, quinidine
- Antimalarial drugs: chloroquine, hydroxychloroquine, quinine
- Antidepressants/anxiolytics/antipsychotics/AEDs: amitriptyline, carbamazepine, chlorpromazine, levomepromazine, methoprazine, imipramine, lorazepam, phenytoin
- Diuretics: thiazide diuretics, furosemide, spironolactone
- Antidiabetics: sulfonylureas
- Metals: gold salts, arsenic, bismuth, mercury, palladium, lithium
- NSAIDs
- 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
Plaques
- Psoriasis
- Bowen disease
- Discoid lupus erythematosus
- Drug eruption
- Erythema annulare centrifugum
- Lichen planus
- Lichen simplex chronicus
- Nummular dermatitis (nummular eczema)
- Parapsoriasis
- Pityriasis rosea
- Seborrheic dermatitis
Diagnosis
- Clinical diagnosis
- Workup outside of ED may include:
- Punch biopsy or shave biopsy
- Immunofluorescence studies if bullous lesions present
- Routine HCV testing controversial
Management
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, Ultraviolet 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
See Also
External Links
References
- Goldstein, BG, Goldstein, AO, Mostow, E. Lichen planus. In: UpToDate, Dellavalle, RP, Callen, J (Ed), UpToDate, Waltham, MA, 2017.