Lichen planus: Difference between revisions
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Revision as of 13:00, 24 September 2017
Background
- Uncommon disorder of unknown cause
- Estimated < 1% occurrence rate, most frequently 30 to 60 years of age
- Proposed immune-mediated mechanism, T cells (primarily CD8+) activated against basal keratinocytes
- 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 anterior lower legs
- Occasionally develops cutaneous squamous cell carcinoma
Annular lichen planus
- Violaceous plaques with central clearing (central atrophy may occur)
- 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 Middle East, India, and east Africa
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
Atrophic lichen planus
- Violaceous, round or oval, atrophic plaques
- Common sites are legs
Lichen planopilaris (follicular lichen planus)
- Classic site is the scalp
- May be in other body sites (e.g., Graham-Little-Piccardi-Lasseur syndrome)
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
- Occurs on the scalp causing hair loss with keratotic follicular papules
- 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:
- 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
- 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
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
Biopsy (e.g., punch biopsy, shave biopsy)
- Immunofluorescence studies if bullous lesions present
Dermoscopy
- Wickham’s striae
HCV testing
- Routine testing controversial
Histopathology
- Pathologic findings seen in lichen planus
- Hyperkeratosis without parakeratosis
- Apoptotic keratinocytes in lower epidermis (Civatte bodies) and papillary dermis (eosinophilic colloid bodies)
- Wedge-shaped hypergranulosis
- Bandlike infiltrate of lymphocytic and histiocytic cells
- Linear or shaggy deposits of fibrin and fibrinogen in basement membrane
Managment
Cutaneous lichen planus
- 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 lichen planus
- Topical corticosteroids or topical calcineurin inhibitors
Lichen planopilaris
- Topical corticosteroids or intralesional corticosteroids
Oral lichen planus
- Topical corticosteroids
Nail lichen planus
- Systemic or intralesional corticosteroids
Disposition
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)