What is Lichen Planus?

Lichen planus (pronounced LY-KEN PLAN-US) is a fairly common skin disease which affects 1-2% of the population.  It is somewhat unique among rashes because it can affect skin, mucous membranes, hair, and nails.  In this article, we will focus mainly on lichen planus of the skin and mouth.

Skin Lichen Planus
Lichen planus of the skin affects all races and men and women equally between the ages of 30 and 60 years.  It was first recognized in 1869.  The rash consists of many small reddish purple bumps that are extremely itchy.  While the rash can occur anywhere on the body skin, the most common areas are the inside of the wrists and ankles, hands and feet, waistband area, neck, and mid-low back.  Facial involvement is rare.  The diagnosis can be established with certainty with a skin biopsy.

When the bumps begin to flatten either with treatment or spontaneously, they leave a dark brown stain (not a scar) that will eventually fade.  If the skin of a person with lichen planus is scratched deeply or cut, even if by planned surgery, the healing injury may turn into lichen planus.  This unusual phenomenon can also be seen with psoriasis.

Cause and Treatment
While the cause is unknown, the conventional wisdom is that the skin disease is an inflammatory reaction in the skin caused by a malfunction of the immune system or a hypersensitivity reaction to an infection,  such as a urinary tract infection,  or an allergic reaction to a drug.  Many drugs have been associated with lichen planus, but the more common ones in my experience are the non-steroidal anti-arthritis drugs such as naproxen and the common water pill called hydrochlorothiazide (HCTZ).

Naturally, if there is an infection, that should be treated with the appropriate antibiotic.  Sometimes the rash will fade rapidly if the infection was the cause of the lichen planus.  Stopping the suspected drug may also bring about successful clearing of the skin, although that may take several weeks to occur.  The majority of cases, however, will not respond to antibiotics  or drug removal, because their disease is  a sign of autoimmunity.  In other words, the patient’s own immune system, in the form of circulating lymph cells, is attacking the top layer of skin (the epidermis) which produces the visible rash.

The majority of lichen planus patients are treated with potent prescription corticosteroid ointments which help to flatten bumps and reduce itching.  We  may also recommend  anti-histamines which also improve itching and sleeping at night.  For more widespread lichen planus rash, we may give a long-acting injection of the steroid in the office, or prescribe prednisone pills for a few weeks.  Sometimes these measures put the lichen planus into a quiet state for a while, but there is a strong tendency for it to recur.  Steroid-resistant cases of lichen planus may respond to ultraviolet phototherapy in the office in the same manner as we use it for severe psoriasis.  The duration of suffering from lichen planus may last for months to 5 years, with an average of 2 years.

Oral Lichen Planus
Lichen planus of the oral cavity affects more women than men (about 2 to 1), and the average age of onset is older than for skin (about 52 years), suggesting that there may be immunological differences between the two different sites.  However, the biopsy findings and immunological stains are nearly identical in skin and mucous membranes.  Any part of the oral cavity may be affected by lichen planus, but the most common areas are the

Fine white striae surrounded by redness

inside of the cheeks, tongue, and gums.  When there is particularly severe redness, swelling and bleeding of the gums due to lichen planus in a woman, there is about a 20% chance of severe genital involvement as well.  In severe cases affecting the roof of the mouth or back of throat, swallowing may become impaired due to involvement of the esophagus.

The lesions of oral lichen planus are more varied in appearance than on skin.  For example, the most common type of lichen consists of fine white lines (striae) and does not cause any symptoms.  When we see redness between the white lines, there is usually more burning or pain felt by the patient.  Some lesions just show thin red patches, but the worst cases demonstrate widespread open erosions and ulcers in the mouth, making eating, drinking, even speaking, difficult if not impossible.

Treatments of Oral Lichen Planus
Based on the wide range of severity that is possible, treatments range from none to high doses of prednisone and other immunosuppressive drugs.  For the typical moderate case of lichen planus with striae and redness and oral discomfort, we prescribe steroid rinses or dermatological gels which are very effective for symptoms.   It has been shown that about 30% of oral lichen planus patients also have yeast (Candida) infections in their mouths.  Therefore, we also prescribe an anti-yeast medicine to be used along with the steroid.  These patients usually do well with treatment, and the doseage of medicines can usually be reduced, but constant maintenance is required because the disease relapses 90% of the time!

The more severe cases are of course more difficult to manage.  The high potency internal drugs that suppress the immune system do significantly reduce the inflammation, pain, and allow healing to occur, but usually cannot induce a complete remission or cure.  In addition, there are many potential risks and side-effects that require monitoring by the experienced physician.  I will list some of the drugs used here for those who are interested, so that you may do further research or ask your own physician about: prednisone, acitretin, cyclosporine, mycophenolate mofetil, azathioprine, thalidomide.

Interesting Associations with Oral Lichen Planus
Naturally, patients with oral lichen planus may have lichen planus in other anatomic areas.  Skin involvement occurs in about 15% of oral cases, and oral involvement may seen in up to 50% of skin cases.  However, my experience managing over 1000 cases over the years has taught me that severe cases in one area have minimal to no involvement in the other area.

The association of hepatitis C virus infection with oral lichen planus is controversial.   In the recent past, it was recommended to screen for the hepatitis C antibody and measure liver enzymes in patients with oral lichen planus.  Now we understand that there is an association between hepatitis C and oral lichen planus in countries that have a high prevalence of hepatitis C infection such as Italy, Spain and Japan, but not in the US, UK, or Germany.  I do not order these tests unless a case is particularly resistant to standard therapy.

Just as with skin lichen planus, many drugs have been implicated as the cause of oral lichen planus.  This has been difficult to prove for a number of reasons, however, the non-steroidal anti-inflammatory drugs including naproxen, ibuprofen and many others as well as the ACE inhibitor class of blood pressure medicine (includes lisinopril) are still suspected.

There have been a number of oral cancers reported in association with oral lichen planus, usually of the longstanding severe inflammatory type.  It is possible that the cancers developed as a result of chronic inflammation or due to other risk factors such as genetic, alcohol or tobacco abuse.  Some of the cases did clearly show on biopsies evidence of a progression from lichen planus to pre-cancer to squamous cell carcinoma.

Therefore, we do recommend an oral exam at least every 6 months  for cancer surveillance, stopping tobacco habit, and reducing alcohol intake.

Finally, one of the most interesting associations is the reaction to corroded dental metal fillings, especially large ones when the filling lies adjacent lichen planus lesions on the inside of the cheek or tongue, or the surrounding gum tissue.  These patients are often sensitive to the mercury content of the silver amalgam filling.  A special type of allergy patch testing can be done to demonstrate the reaction on the skin.  In such positive cases, I advocate removal of the metal fillings and replaced with white resin material.  In studies showing positive mercury patch tests, the rate of complete clearance has been 100% within months of the procedure!  Unfortunately, this type of oral lichen planus accounts for only 1% of the cases.

More About Autoimmune Diseases:
Painful Oral Erosions and White Patches
Two Novel Treatments for Oral Lichen Planus Hold Promise

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18 Responses to What is Lichen Planus?

  1. Esther Strotjohann says:

    I just want to thank Dr. Camisa for his treatment of my Lichen Planus that had been active for 2 years before I saw him. I thought I would have to live with it forever but with Dr Camisa’s treatment it has been under control for 9 months now. He is a wonderful doctor and person.

    • DrCamisa says:

      Thank you for your very kind comments, Esther. I’m planning to write a blog on how efficient dermatologists can be in diagnosing and treating some difficult skin diseases.

      • Chris Morris says:

        I would be interested in any additional information – I have been dealing with lichen planus in mouth and vulva area for several years and have it under control for the most part; however, recently was diagnosed with lichen planophilarius in my scalp… and am losing hair rapidly. Any help would be appreciated as there is very little information available.
        Thanks!

        • DrCamisa says:

          Lichen planopilaris is the name for lichen planus of the hair follicle. It can affect any hair-bearing area, but the scalp is most common. The inflammation of the hair follicle may lead to scarring and permanent hair loss. This process can progress with alarming speed as you mentioned. That is why I usually recommend the early use of moderately high doses of steroids such as prednisone gradually tapered off and followed by an immunosuppressive drug such as CellCept or Imuran. Vulvar, oral, especially the gums, and scalp lichen planus can all occur simultaneously and are challenging to treat.

  2. Robert Dannenhoffer says:

    I have been taking Lisinopril HCTZ for quite a number of years. Should I discuss changing this medication with my doctor?

    • DrCamisa says:

      It may be worthwhile so long as your doctor can either switch you to a different class of anti-hypertensive medication, or monitors your blood pressure very closely while you are off all medications. It takes about a month off medication to be able to tell whether stopping it helped improve the lichen planus.

  3. Amy Nelson says:

    I was diagnosed in early Dec. with LP and NOTHING has worked. I am miserable, it’s on my genitals, all over from my neck down, my scalp has been itching, inside of my mouth on my cheeks and the bottom of my feet are so bad it hurts to walk. What can I do??

    • DrCamisa says:

      Severe generalized LP can be miserable to live with. I suggest you connect with a dermatologist in your area who has experience and an interest in treating complex autoimmune skin diseases. You may need to go to a medical school with a dermatology clinic. There are many medicines available to treat the most resistant cases of LP, but internal corticosteroids such as oral prednisone or intramuscular injections are usually given first, to reduce the inflammation rapidly before starting the slower-acting immunosuppressive medicines.

      • Amy Nelson says:

        Thank you Dr. Camisa, I am actually going to USF today. Fingers crossed!! I’ve tried oral prednisone, griseofulvin and a few different creams as well as atarax. So hopefully USF will have something different to offer.

  4. jane says:

    I have had lichen planus everywhere pretty much -once. I believe mine is from an allergic reaction to a medication. I have type 2 diabetis, high blood pressure, high cholesteral. I was taking lisinopril, glipizide,& janumet before i got it And still am. I cant get anyone to believe me plus no insurance. I always feel extremely tied. Not just diabetic tired. I always feel a little sick as if i am being poisoned. I have large amounts of hair come out when i brush or wash my hair. I am slowly getting worse. I have mostly given up hope for someone to want to see what is wrong with me. I dont care what anyone says- there is something else going on in me they arent seeing or looking for.

    • DrCamisa says:

      Any one of the drugs you listed can cause a lichen planus-like drug eruption. The only way to find out for sure is for each one to be stopped one-at-a-time for one full month to see if spontaneous improvement occurs. If so, then that is the drug that must be eliminated permanently and replaced with a different drug if necessary.

  5. Sheron says:

    3 years ago I had lichen planus in my skin and I don with that. 2 years ago I got lichen planus in my mouth-
    Tongue and gum. (Whit lines with a little redness)
    I’m 27 years old woman.
    What is the risk/rate (%)
    That I will get lichen planus in my vulva also?
    I’m very worry.
    Thank u doc

    • DrCamisa says:

      If the gum involvement is very severe, the risk of vulvar involvement can be as high as 1 in 5.

      • Sheron says:

        Thank u !!!
        My gum is not very severy. Mostly reticular. But my I want to know if my vulva can affected 2 years after my mout?

      • Sheron says:

        And one mor thing:
        The risk of vulva involvement is different if my lichen planus start in my skin and than in my mouth. I mean, if the risk of vulva involvement is lower after my body skin was affected first?
        Thank u a lot !
        Sheron.

  6. Kishore Chandur Ganglani says:

    Dr i need your help here in my country ive been to several dermatologist all with different analysis of my skin disorder …..but seing photho in internet i have mild case of lichen planus on my wrist and ankles and legs and on my back …..pls let me know how i can contact you ….im from philippines

  7. Alka says:

    Dr i have been suffering from lichen planus Fi have rashes on my hands & on back .

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