LICHEN PLANUS

Synopsis :


Definition
History and epidemiology
Aetiopathogenesis
Clinical features
Classification
DD
Management
Prognosis



Introduction :


Papulosquamous inflammatory disorder characterized by

• Distinctive color - Violacious
• Morphology – Flat topped papule
• Typical Location – Volar aspect of extremities
• Characteristic pattern of evolution

Affect skin, mucous membrane, nail and hair


Prototype of lichenoid eruption

History :

Lichen = tree moss    Planus = flat

LP – name given by Erasmus Wilson in 1869

Whitish striae and punctation on flat LP lesion described by Wikham in 1895

Histological findings elaborated by Darier in 1909

Epidemiology :

Worldwide distribution

No racial predisposition

Less than 1% of general population affected

Age
Male – earlier
Female – late
Extremes of age – less common

Aetiopathogenesis :

Immunologically mediated disease in genetically susceptible individual

Other association –
Cutaneous LP - Hepatitis C, Anxiety and depression
Oral LP - Mercury and Gold sensitization

Clinical Features :

Shiny, violaceous, flat topped,     polygonal, pruritic papules with ‘wickham striae’ and koebnerization

Insidious onset and size ranges from pinpoint to centimeters

Koebnerization 

Wickhams striae  

Affect Volar aspect of wrists, ankles, lumbar region with bilateral symmetrical distribution

Oral mucous membrane and genitalia are additional site of involvement

Pruritus - mild irritation to intolerable

Pinkish papule change to violaceous then to brown macule as disease progress

Variant of LP


Configuration

• Annular
• Linear

Site of involvement

• Palm and sole
• Mucous membrane
• Nail
• Scalp

Morphology of lesion

• Hypertrophic
• Atrophic
• Vesicobullous
• Erosive and Ulcerative
• Follicular
• Actinic
• Lichen Planus Pigmentosus
• Others

Diagnosis

Clinical feature



Histology

Histology

Compact orthokeratosis
Wedge shaped hypergranulosis
Irregular acanthosis
Vacuolar alteration of the basal layer
Band like dermal lymphocytic infiltrates
Colloid bodies
Max –Joseph spaces

Management of LP

Challenging for both patient and physician

Only minor symptoms or considerable discomfort and disability

Many drugs lack conclusive evidence for efficacy

Oral LP


General measure


Good oral hygiene and regular professional dental care

Offending drugs or dental amalgam, gold- withdrawal and replacement

Topical lidocaine  gel or Diphenhydramine for pain relief

Topical steroids 

• First line therapy in mucosal LP
• Triamcinolone in orabase
• Clobetasol propionate in ointment or paste
• Corticosteroid lozenges
• Betamethasone mouthwash
• Fluticasone propionate spray

Intralesional injection

Chlorhexidine mouth wash and anticandidal  drug therapy

Hydrocortisone vaginal pessary

Systemic Glucocorticoids

For extensive, ulcerative/erosive lesion of oral and vulvovaginal LP

Used alone or in conjunction with topical therapy

Prednisolone 30-80mg/day tapered over 3-6 weeks

Relapse after dose reduction or discontinuation

Retinoids

Topical tretinoin gel for erosive and plaque like lesion – less attractive because of irritation

Isotretinoin gel for nonerosive oral lesion-improves in 2 months-recovers after discontinuation

In conjunction with topical steroid

Acitretin 30mg/day complete remission in 8 weeks

Cyclosporine

Oral – 3-10mg/kg/day in severe ulcerative disease
Topical – beneficial but not available commercially

Tacrolimus

Effective in erosive mucosal disease-rapid relief from pain and burning

Miscellaneous

Griseofulvin – used empirically
Fluconazole, itraconazole – for candidal overgrowth, concomitant use with systemic steroid
Hydroxychloroquine –  200-400mg/d for 6 months – complete healing of oral lesion
Azathioprine, cyclophosphamide
Laser therapy
Surgical excision of persistent ulcer

Cutaneous LP

Topical Glucocorticoids

For limited cutaneous disease
Potent creams is sufficient for  symptomatic relief for small area, larger area needs dilution

Intralesional trimcinolone acetonide

(5mg to 10mg/ml) every 4 week – lesion regress within 3-4 months
Hypertrophic LP:-10-20mg/ml
Monitor for atrophy or hypopigmentation

 Antihistamines for itching

Retinoids :

Acitretin : 30 mg / day for 8 weeks

Tretinoin : 10-30 mg/d

Etretinate : 10-20 mg/d

Photochemotherapy :

PUVA in generalized cutaneous LP

50 mg of Trioxsalen in 150 L  of water - 10 min of UVA bath

75 patients – 65% cured ; 15% improved

Immunosuppressive therapy 

Cyclosporine: 3-10 mg/kg/d

Azathioprine , mycophenolate mofetil

Ind : recalcitrant LP

Miscellaneous :

Dapsone : 200 mg/d

Hydroxychloroquine : 200-400 mg/d

IFN- α2b

Metronidazole : 500 mg b.d

Cyclophosphomide ,methotrexate

Prognosis :

Unpredictable ; 1-2 yrs

Duration  α  extent /site/ morphology

L planopilaris : most chronic

Generalised : rapid course

Gen < skin

Relapse : 15 -20 %