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For further information, see CMDT Part 6-40: 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

  • Histopathologic examination is diagnostic

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

  • Lichenoid drug eruptions can resemble lichen planus clinically and histologically

  • Most common medications 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

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 ankles

      • Lower back

      • Mucous membranes, including the penis, lips, tongue, buccal, vulvar, vaginal, esophageal, and anorectal mucosa

  • 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

Diagnosis

Laboratory Tests

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

Treatment

Medications

TOPICAL THERAPY

  • See Table 6–2

  • Superpotent topical corticosteroid ointments

    • Examples are betamethasone dipropionate 0.05% in optimized vehicle, diflorasone diacetate 0.05%, clobetasol propionate 0.05%, and ...

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