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Chapter 160: Lichen Planus

Robert L. Kraft; Richard P. Usatine

PATIENT STORY

A 38-year-old Hispanic woman presents with a rash on her forearms, wrists, ankle, and back (Figures 160-1, 160-2, 160-3, 160-4). She states the rash is mildly itchy and she does not like the way it looks. She would like some medication to make this better. Lichen planus (LP) was diagnosed and clobetasol was prescribed to keep the LP under better control.

FIGURE 160-1

A 38-year-old Hispanic woman with lichen planus on her wrist. (Reproduced with permission from Richard P. Usatine, MD.)

A photo shows small dark red spots in the lower arm and wrist.
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FIGURE 160-2

Close-up of wrist showing linearity of the lesions on the flexor surface. Lesions may be pink rather than purple. (Reproduced with permission from Richard P. Usatine, MD.)

A photo shows close-up view of the lesions, which appear as small pinkish bumps on the skin. Some of them are arranged linearly.
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FIGURE 160-3

Ankle of the woman in Figure 160-1 with typical lichen planus eruption. (Reproduced with permission from Richard P. Usatine, MD.)

A photo shows small, reddish bumps on the ankle and foot.
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FIGURE 160-4

A. Lichen planus on the back of the woman in Figure 160-1. B. Close-up of lesions on the back showing Wickham striae crossing the flat papules of lichen planus. These lines are white and reticular like a net. (Reproduced with permission from Richard P. Usatine, MD.)

Two photos show lesions of lichen planus. One shows multiple reddish eruptions along the spine, in the back. Other shows close-up view of the eruptions, which appear as almost flat papules with whitish scaling.
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INTRODUCTION

LP is a self-limited, recurrent, or chronic autoimmune disease affecting the skin, oral mucosa, and genitalia. LP is generally diagnosed clinically with lesions classically described using the six Ps (planar, purple, polygonal, pruritic, papules, and plaques).

EPIDEMIOLOGY

  • LP is an inflammatory dermatosis of skin or mucous membranes that occurs in approximately 1% of all new patients seen at healthcare clinics.1

  • Although most cases occur between ages 30 and 60 years, LP can occur at any age.1,2

  • There may be a slight female predominance.2-4

ETIOLOGY AND PATHOPHYSIOLOGY

  • Usually idiopathic, thought to be a cell-mediated immune response to an unknown antigen.2,3,5

  • Possible human leukocyte antigen (HLA)-associated genetic predisposition.2

  • Lichenoid-type reactions may be associated with medications (e.g., angiotensin-converting enzyme inhibitors [ACEIs], thiazide-type diuretics, tetracycline, chloroquine), metals (e.g., gold, mercury), or infections (e.g., secondary syphilis).2,5

  • Associated with liver disease, especially related to hepatitis C virus.2,5,6

  • LP may be found with other diseases of altered immunity (e.g., ulcerative colitis, alopecia areata, myasthenia gravis).1

  • Malignant transformation has been reported in ulcerative oral lesions in men.1

RISK FACTORS

  • Possible HLA-associated genetic predisposition.

  • Hepatitis C virus infection, although causal relationship is not established.6

  • Certain drugs (see "...

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