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Lichen planus

If you’ve been suffering from purple-looking rashes accompanied by very bad itching, please visit a dermatologist. You could be suffering from what is called Lichen planus. Lichen Planus is a chronic inflammatory disease of the skin that affects one’s skin, mucous membranes and hair. Since the lesion resembles lichen, the condition is termed as lichen planus. Lichen planus is not an infectious disease; therefore, it cannot spread from person to person; moreover, it is not a type of cancer.

The exact prevalence of lichen planus is unclear; this disease affects 0.5%–2.0% of the general population. India has a high incidence of lichen planus, with a prevalence rate of 2.6%. The incidence of this condition is 13.7% in tobacco users and 0.3% in non-tobacco users. Lichen planus affects patients between 30 and 60 years of age and is more common in females than in males.

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Types

Several types of lichen planus exist, which require histological examination for the correct diagnosis. The location and symptoms vary in different variants of lichen planus. Various types of lichen planus are listed below:


  • Oral lichen planus

  • Nail lichen planus

  • Linear lichen planus

  • Annular lichen planus

  • Atrophic lichen planus

  • Hypertrophic lichen planus

  • Inverse lichen planus

  • Eruptive lichen planus

  • Bullous lichen planus

  • Ulcerative lichen planus

  • Lichen planus pigmentosus

  • Lichen planopilaris

  • Genital lichen planus

  • Actinic lichen planus

  • Lichen planus-lupus erythematosus overlap syndrome

  • Lichen planus pemphigoides

Symptoms


  • The most common symptom of lichen planus is experiencing severe itching or pruritus. The intensity of itching can vary from mild to severe in different patients. The subsequent lesions formed are purple to violaceous in colour and flat in appearance. There can be multiple types of lichen planus depending on the area affected.

  • Lichen planus of the skin: Lichen planus can occur on the skin because of any trauma such as scratch, cut, or burn. Skin sores appear on the legs, torso, inner wrist, or genital area. They have symmetrical and sharp borders and are extremely itchy. They have a dark violet colour and have a shiny or scaly appearance. They can either exist alone or in clusters. Skin sores may develop into ulcers. For stable lesions (long term, non-spreading lesions) of lichen planus, one will usually have very deep residual pigmentation, which takes many years to improve. Skin bumps are then replaced by dark brown coloured patches, which usually fade after a few months.

  • Oral lichen planus: In an oral lichen planus, it forms ulcers or erosions, which can be quite painful. Mouth ulcers are tender and are located on the sides of the tongue, gums, or inside of the cheek. They look like bluish-white pimples and form a lacy network; these ulcers gradually increase in size.

  • Lichen planus of the hair: On the scalp, there is cicatricial alopecia (hair loss in patches) with permanent hair loss. Patients with lichen planus on the scalp experience tiny bumps, redness, and irritation. Most patients will notice a cracking and thickening of the skin on the palm and soles as well.

  • Lichen planus of the nails: Lichen planus in the nails causes brittle or split nails and ridges in the nails.

  • Genital lichen planus: Women with genital lichen planus experience bright red patches or sores in the vagina or vulva. Usually, genital lichen planus does not cause symptoms, but the sores are quite tender.


Other symptoms of lichen planus are dry mouth, metallic taste, hair loss, and ridges in the nails.

Causes And Risk Factors

Causes

Lichen planus is an autoimmune disease with an unknown initial trigger. Since the reason for the onset of this condition is unknown, anybody can suffer from it. Lichen planus can occur because of:


  • Hepatitis C virus.

  • Certain medications used to treat high blood pressure, diabetics, heart disease, bacterial infection, malaria, and painkillers.

  • Reaction to metal fillings in the mouth.

  • Certain chemicals used to develop coloured images.


Risk Factors

But there are some people who are in higher risk groups. For instance, patients on certain drugs like beta blockers, antimalarial drugs, metformin and penicillamine have risk of triggering lichen planus. Apart from that the condition is largely seen in children and females suffer more from it as compared to males. Females are twice as likely to get oral lichen planus compared to men.

Prevention

Since the reason for this condition is still unknown, there is no known way to prevent the condition. Although there is no known way to prevent the onset of the condition, avoiding certain drugs and dental amalgams can prevent recurrence. Moreover, acute infections should be treated promptly, and the patient should learn to relax and lower their stress levels – since it can also trigger a reaction.

Diagnosis

It is fairly simple to distinguish between a rash due to lichen planus and one that’s not due to the condition. One distinguishable characteristic is the colour of the rashes. Lichen planus is classically purple in colour and is accompanied with intense itching. Moreover, lichen planus commonly affects areas like the wrists, inner part of the forearms, legs, chest and back.

In most cases the diagnosis of the condition is fairly simple and is based on the symptoms that the patient has. The doctor may perform a blood test to exclude other causes for symptoms. Diagnosis is mostly clinical in classic cases but if a doctor is not sure then a skin biopsy helps give a confirmation through a microscopic examination of the skin sample.

Treatment

If you are diagnosed with lichen planus but do not show any symptoms, no treatment is required. This condition can disappear within two years. Treatment can help if you have symptoms such as severe itching and sores in the mouth or genital area. Lichen planus of the scalp requires treatment to prevent permanent hair loss. There is no cure for lichen planus, but many treatment options are available to give symptomatic relief, speedy recovery, improve the cosmetic concerns of a patient, and to maintain disease under control.

Medical treatments include:


  • Antihistamines are prescribed to reduce itching

  • Topically applied moderately potent corticosteroids.

  • Inhalant powders are used for oral lichen planus.

  • Tacrolimus and pimecrolimus are used as alternatives to topical corticosteroids

  • Skin lightening creams to improve active and pigmented lesions.

  • An ultra-violet light treatment called PUVA.

  • Carbon dioxide laser and YAG laser treatment.

  • Retinoids that are derived from vitamin A.

  • Oral steroids

  • Cyclosporine

  • Methotrexate

  • Alternative drugs



  • Antimalarial drugs such as hydroxychloroquine.

  • Antibiotics such as dapsone, and metronidazole

  • Antifungals such as griseofulvin

Lifestyle/management

To prevent worsening of lichen planus, you can take the following steps:


  • Avoid any injury to the scalp or skin.

  • Avoid scratching. Use cold compresses instead.

  • Reduce stress.

  • Avoid smoking tobacco and drinking alcohol.

  • Sustain good oral hygiene.

  • Avoid foods that may irritate your mouth.

  • Visit a dentist or dermatologist twice a year for a screening of oral cancer.

Prognosis And Complications

Prognosis

Lichen planus is not a harmful disease. It usually goes away on its own. The duration of the disease can vary from patient to patient. In some patients, lichen planus can stay for years. Oral lichen planus lasts longer than the skin lichen planus. In a few cases, lichen planus can recur. Lichen planus often leaves a dark brown discolouration on the skin, which eventually fades away without any treatment. Patients with oral lichen planus are at a slightly greater risk for developing oral cancer. Such patients should avoid tobacco smoking and alcohol consumption and should go for a regular screening with the dentist/dermatologist.

Complications

There are no serious side effects or complications of any of the forms of treatments used for patients with lichen planus. Some studies suggest that this condition may be an early sign of oral cancer. One should definitely make sure they visit their doctor regularly to keep a check on the progress of the condition.

Alternative Treatments

Alternative treatments such as meditation, relaxation, and hypnosis can positively influence on lichen planus and other skin conditions. It can help to calm and restore the balance of the inflammatory response, which can ameliorate lichen planus.

References

 


  1. Lichen planus. American Skin Association. Available at: https://www.americanskin.org/resource/lichen.php. Accessed on Mar 23, 2021. (https://www.americanskin.org/resource/lichen.php)

  2. Gupta S, et al. Indian J Dermatol. 2015;60(3):222-9.

  3. Weston G, et al. Int J Women’s Dermatol. 2015;1(3):140-149.

  4. Lichen planus. MedlinePlus. Available at: https://medlineplus.gov/ency/article/000867.htm. Accessed on Mar 23, 2021. (https://medlineplus.gov/ency/article/000867.htm)

  5. Lichen planus. University of Rochester medical center. Available at: https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=134&contentid=220. Accessed on Mar 23, 2021. (https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=134&contentid=220)


 

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