What is Lichen Planus?
Lichen Planus is a rash that can develop on the skin, tongue, scalp, and oral mucosa. Lichen planus is an inflammatory skin condition and it is believed to be an autoimmune disease. The typical rash of lichen planus has been described as the “5Ps”, pruritic, planar, purple, polygonal, and papules. The rash is common around the wrist and ankles and persists for weeks, often turning blue-black or dark brown with discolored patches on the skin.The lichenoid eruption may appear as papules, pruritic bumps, blisters, or rarely as erosive sores particularly in mucous membrane areas.
Who Can Get Lichen Planus?
Lichen planus is most commonly seen in middle-aged adults, however, anyone can get this disease. Lichen planus affects more women than men in cases where the disease is seen in the mouth.
Symptoms of Lichen Planus
The symptoms of lichen planus depend on the area of the body that’s being affected.
Cutaneous Lichen Planus (Skin)
Papules can start to appear abruptly – they are characterized as red or purple bumps that are slightly raised with a flat top. The papules measure around 3-5 mm in diameter and may also contain white streaks or white lines which are called Wickham’s striae. Severe itching can occur which is worse during the night.
The lesions of lichen planus can appear anywhere on the body but are more commonly seen on the wrists, elbows and back. Thicker scaly patches can also appear on the ankles which is referred to as hypertrophic lichen planus. On the legs, the papules appear to be darker than other parts of the body.
Oral Lichen Planus (Mouth)
Lichen planus occurs mostly on the sides of the cheeks, however, it’s also common to appear on the gums, lips, and tongue. Clinically, lichen planus presents with white patches with striae on the tongue and oral cavity. Lichen planus can cause painful oral lesions on the gums as well. These painful sores can recur and can make eating and even drinking painful. In addition, spicy foods can exacerbate these symptoms as it can make these sores more irritated.
Atrophic lichen planus is a rare form of LP and it is characterized by pale papules or plaques which can develop inside the mouth or on the skin.
Oral lichen planus should not be confused with oral thrush. Oral thrush is an infection in the mouth which is caused by the yeast, Candida. Candida is normally found in the mouth. However, certain situations such as a weak immune system, can trigger the overgrowth of Candida, leading to infections. Characteristics of oral thrush can resemble those seen in oral lichen planus – white patches on the gums, within the cheeks, and burning sensations when eating or drinking.
Lichen Planopilaris (Scalp)
A rare manifestation of lichen planus is on the scalp, called lichen planopilaris. This can cause redness, irritation, and patchy hair loss and even scarring. As the lichen planus progresses in the scalp, the scalp can become more scarred and areas of hair loss or alopecia progress.
Vulval Lichen Planus
Lichen planus can affect the female genital area, specifically the labia majora, labia minora and vaginal introitus. White streaks can also appear on the vulva , appearing similar to the ones which appear in oral lichen planus. The disease can affect deeper parts within the vagina, causing severe, painful, desquamative vaginitis. The vagina can easily bleed on contact. In severe cases, painful and continuous ulcers can appear which is known as erosive lichen planus.
Nail Lichen Planus
The nails may be affected as well in lichen planus. Lichen planus causes the nail plate to thin resulting in ridging or grooves on the nails. The nails can become dark in color, thicken or even fall off. In rare cases, the nails can completely disappear, known as anonychia.
How is Lichen Planus Diagnosed?
Dermatologists are able to make a diagnosis based on the clinical manifestations of the rash. Often times lichen planus can be mistaken for other rashes such as eczema, since they both present as itchy, scaly and erythematous patches. In order to confirm the diagnosis, a small biopsy is taken to be studied by the dermatopatholgist. For oral lichen planus, a dermatologist or endodontist can diagnose and treat this oral ulcers, and a biopsy may again be necessary to help with the diagnosis to confirm the best course of treatment.
Complications of Lichen Planus
Chronic erosive lichen planus can result in cancer, more specifically squamous cell carcinoma (SCC). Other cancers such as oral cancer or genital cancers of both male and female can form, specifically vulval cancer in women and penile cancer in men.
Sometimes the affected area can become pigmented or discolored after the lichen planus rash has resolved. This type of healing is referred to as post-inflammatory hyperpigmentation. It’s often more noticeable in patients with darker skin.
Risk Factors of Lichen Planus
Lichen planus affects middle-aged adults, it rarely occurs in children. Females are more prone to getting oral lichen planus than men. Patients which have lichen planus may also have liver diseases such as cirrhosis or hepatitis C virus. The exact cause of how these diseases are linked is still unclear.
What Causes Lichen Planus?
The cause of lichen planus still remains unknown but it is believed to be an autoimmune disease. An autoimmune disease is when a person’s immune system mistakenly attacks the body. Why the immune response manifests in this rash is still unclear. What is known is that lichen planus is not contagious. A patient with lichen planus cannot spread the disease to anyone else. This skin disease also doesn’t appear to run in families. Lichen planus does not appear to be hereditary.
In addition, lichen planus has been described as a reaction towards certain medications such as beta-blockers, anti-inflammatory medications, antimalarial medications, thiazide diuretics, and gold injections (which are used to treat arthritis).
Treatment of Lichen Planus
According to the American Academy of Dermatology, there is no cure for lichen planus. However, through studying lichen planus in many clinical trials, there are various treatments if symptoms become severe. For mild cases of lichen planus, medication is not needed and it often resolves on its own.
Topical corticosteroids can help treat inflammatory lesions and reduce the pruritus and redness caused by lichen planus. Oral corticosteroids, such as prednisone are given when topical steroid creams or ointments are not working effectively. Some side effects of corticosteroids are weight gain, increased appetite or insomnia.
Tacrolimus or pimecrolimus ointments have also showed to be effective in treating lichen planus.
Retinoids such as acitretin are also prescribed in severe cases of lichen planus. This medication can cause side effects such as dryness, irritation, hair loss, muscle pain, or weight gain. Your dermatologist can determine if this is the right treatment option. Cyclosporine is given when oral retinoids or corticosteroids do not working effectively.
Phototherapy can also help clear the skin in cases of lichen planus. There are two types of uv light used, ultraviolet B (UVB) and psorlane plus ultraviolet A (PUVA). UVB is more commonly used to treat lichen planus. However, PUVA is recommended to use in severe cases of lichen planus.
Antihistamines such as Zyretc, Atarax, and Benadryl, can also be given to help alleviate any itching.
For oral lichen planus, treatment depends on the degree of discomfort that a patient is experiencing. Mild symptoms may be treated with topical steroids and more severe symptoms may require oral corticosteroids or injections.
Home Remedies for Lichen Planus
Some studies suggest home remedies may help ease the symptoms of lichen planus. Turmeric has been shown to reduce inflammation and can be used to treat oral lichen planus. Other suggestions include chewing sage and using aloe vera gels or essentials oils on the skin. Currently, there is not enough research to support the effectiveness of many home treatments. It is highly recommended to get a check up from a board certified dermatologist and the correct treatment from a qualified health care professional.
COVID-19 Coronavirus & Lichen Planus
It’s always important to maintain good personal hygiene and oral hygiene, especially during the pandemic with coronavirus. While lichen planus is not contagious, it can sometimes be confused with other contagious rashes. Proper hand washing regularly for 20 seconds with soap and water or alcohol-based hand rub and staying isolated when feeling unwell, all help to decrease the spread of infections.
Many cases of skin lichen planus disappear within two years. However, as the disease heals, it often leaves pigmentation and discoloration of the affected areas. Dermatologists can lighten these dark spots with lasers, bleaching creams, and additional treatments.