Notes and photos from dermnet – https://www.dermnetnz.org/topics/lichen-planus/
Lichen planus is a chronic inflammatory skin condition affecting skin and mucosal surfaces.
1 in 100 people are affected
mostly > 40 years
about 50% have oral disease – frequently isolated oral disease
about 10 % have nail disease – infrequently isolated
Cause –
the cause is unknown –hence don’t need to refer – or investigate
just reassure – and treat it
its based on a T cell-mediated autoimmune disease, in which inflammatory cells attack an unknown protein within skin and mucosal keratinocytes.
family history and stress can be contributory
injury to skin, herpes zoster and allergies can increase it
Hep C can trigger it
drugs can give rise to a similar rash –Thiazide diuretics, antimalarials, captopril
( antimalarials can also cause psoriasis )
Clinically
papular, purple, polygonal ( noon- circular straight edges ) and pruritic lesions with plaques (color can change) – ( Papular and Plaques which are Polygonal, purple and Pruritic)
Plaques have fine white lines called Wickham striae.
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Size ranges from pinpoint to larger than a centimeter.
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Distribution may be scattered, clustered, linear, annular or actinic (sun-exposed sites such as face, neck and backs of the hands) and anywhere
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commonly distribution is symmetrical – in flexor surfaces – in wrist,s forearms, groins, and ankle + genitals, mouth, nails and scalp
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Plaques resolve after some months to leave greyish-brown post-inflammatory macules that can take a year or longer to fade.
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Without treatment the skin lesions usually resolve over 6 to 9 months, with postinflammatory hyperpigmentation that fades over 3 to 6 months.
However, a small proportion persists, particularly oral and genital lesions.
Involvement of nails and hair follicles (ie lichen planopilaris) may cause permanent atrophy and destruction
Oral lichen planus often involves the inside of the cheeks and the sides of the tongue, but the gums and lips may also be involved
can be painful or painless with or without erosions
can some times give only erosions
D/D – for oral ulcers
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aphthous ulcers with stress
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oral lichen planus
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Behcet’s disease
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Lupus
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SCC
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penile and vulval lesion can also be painless or painful ( penile and valval photos not from derm net )
Symptoms of vulval LP include: ( PHOTO NOT FROM DERMNET)
reddish brown patches on the inner part of the vulva
pain or burning around the vulva and/or vagina
itchiness in the vulvar area.
Lichen planopilaris presents as tiny red spiny follicular papules on the scalp or less often, elsewhere on the body. Rarely, blistering occurs in the lesions. Destruction of the hair follicles leads to permanently bald patches characterised by sparse “lonely hairs”. ( scarring alopecia)
Lichen planus affects one or more nails, sometimes without involving the skin surface. It is called twenty-nail dystrophy if all nails are abnormal and nowhere else is affected
Lichen planus pigmentosus
Lichen planus pigmentosus describes ill-defined oval, greyish brown marks on the face and neck or trunk and limbs without an inflammatory phase. It can be provoked by sun exposure but can also arise in sun-protected sites such as the armpits. It has diffuse, reticulate and diffuse patterns. Lichen planus pigmentosus is similar to erythemadyschromicum perstans and may be the same disease.
Complications –
rear – SCC if long standing
Diagnosis – clinically – but encouraged to do biopsy is not sure of diagnosis
Treatment
If asymptomatic – no treatment – may resolve completely over time ( 9 months – and may leave no scar but leave discoloured marks in skin . recurrence can happen )
If symptomatic –
potent steroid cream
intra dermal steroid injections
oral steroids
methotrexate, azathioprine
phototherapy
Without treatment the skin lesions usually resolve over 6 to 9 months, with postinflammatory hyperpigmentation that fades over 3 to 6 months. However, a small proportion persists, particularly oral and genital lesions.
Involvement of nails and hair follicles (ie lichen planopilaris) may cause permanent atrophy and destruction (eg scarring alopecia).
Refer the patient for expert advice. Treatment may include topical or oral corticosteroids, phototherapy or acitretin. The aim of treatment is to relieve symptoms and prevent permanent damage to hair and nails.