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For further information, see CMDT Part 6-41: Lichen Planus

Key Features

Essentials of Diagnosis

  • Pruritic, violaceous, flat-topped papules with fine white streaks and symmetric distribution

  • Lacy or erosive lesions of the buccal and vaginal mucosa; nail dystrophy

  • Commonly seen along linear scratch marks (Koebner phenomenon) on anterior wrists, penis, legs

  • Diagnostic histopathologic

General Considerations

  • A relatively common (affecting 0.5–2.0% of the population) chronic inflammatory pruritic disease of the skin and mucous membranes characterized by distinctive papules with a predilection for the flexor surfaces and trunk

  • Three cardinal findings

    • Typical skin lesions

    • Mucosal lesions

    • Histopathologic features of band-like infiltration of lymphocytes in the upper dermis

  • Most common drugs causing lichen planus–like reactions include

    • Sulfonamides

    • Tetracyclines

    • Quinidine

    • Nonsteroidal anti-inflammatory drugs

    • β-Blockers

    • Hydrochlorothiazide

  • Hepatitis C infection is found with greater frequency in lichen planus patients than in controls

  • Allergy to mercury and other metal containing amalgams can trigger oral lesions identical to lichen planus

  • Lichenoid drug eruptions can resemble lichen planus clinically and histologically

Clinical Findings

Symptoms and Signs

  • Itching is mild to severe

  • Skin lesions

    • Are violaceous, flat-topped, angulated papules, 1–4 mm in diameter

    • Are discrete or in clusters

    • Contain very fine white streaks (Wickham striae) on the flexor surfaces of the wrists and on the penis, lips, and tongue, as well as on buccal, vaginal, esophageal, and anorectal mucous membranes

  • Mucous membrane lesions have a lacy white network overlying them that may be confused with leukoplakia

  • Mucosal lichen planus in the oral, genital, and anorectal areas may be erosive or ulcerative

  • The papules may become bullous and eroded

  • The disease may be generalized

  • Patients with both oral and vaginal lichen planus are at much higher risk for esophageal lichen planus

  • The Koebner phenomenon (appearance of lesions in areas of trauma) may be seen

  • Squamous cell carcinoma

    • Develops in 5% of patients with erosive oral or genital lichen planus

    • May occur in esophageal lichen planus

    • Risk increased in lesions of hypertrophic lichen planus on the lower extremities

Differential Diagnosis

  • Lichenoid drug eruption

  • Psoriasis

  • Lichen simplex chronicus

  • Secondary syphilis

  • Pityriasis rosea

  • Discoid lupus erythematosus

  • Graft-versus-host disease

  • Mucosal lesions

    • Leukoplakia

    • Candidiasis

    • Erythema multiforme

    • Pemphigus vulgaris

    • Bullous pemphigoid

    • Lichen sclerosus

  • Lichen planus on the mucous membranes must be differentiated from leukoplakia; erosive oral lesions require biopsy and often direct immunofluorescence for diagnosis since lichen planus may simulate other erosive diseases, especially autoimmune blistering diseases that involve the oral mucosa


Laboratory Tests

  • Confirmed by biopsy showing a band-like infiltration of lymphocytes in the dermis




  • See Table 6–2

  • Superpotent topical corticosteroid ointments

    • Examples are betamethasone dipropionate ...

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