Lichen planus in AdultSee also in: Anogenital,Nail and Distal Digit
Alerts and Notices
SynopsisLichen planus (LP) is a condition in which autoreactive T lymphocytes attack basal keratinocytes in the skin, mucous membranes, hair follicles, and/or nail units. The etiology is unclear, but viruses, medications, and contact allergens have all been implicated. LP is most common in adults in the fourth to sixth decades of life, but it may occur at any age. There is no known predilection for either sex or ethnicity. LP is estimated to occur in < 1% of the population.
Clinically, patients present with pruritic, flat-topped, pink to purple papules that are localized most commonly along the volar wrists, shins, presacral area, and hands, but may be widespread. Oral LP and/or LP involving the genitalia can occur in isolation or in patients with cutaneous disease. Lichen planopilaris, a variant of LP affecting the follicular unit, presents with perifollicular erythema and scaling and leads to scarring alopecia. (Frontal fibrosing alopecia is a variant that is seen in older women. Another rare variant is the Graham-Little-Piccardi-Lassueur syndrome.) LP can also affect the nail matrix, resulting in fissuring, longitudinal ridging, and lateral thinning of the nails.
Certain medications cause an LP-like eruption. Culprits include captopril, enalapril, labetalol, propranolol, methyldopa, calcium channel blockers, NSAIDs, chloroquine, hydroxychloroquine, quinacrine, thiazide diuretics, etanercept, infliximab, penicillamine, quinidine, and gold salts.
LP has been described in association with hepatitis C, predominantly in certain geographical areas (Japan and Mediterranean regions). Hepatitis B vaccination as well as exposure to other bacteria and viruses has also been associated with LP in the literature. Oral LP may occur on mucosal surfaces apposed to amalgams and other dental restorative materials.
L43.9 – Lichen planus, unspecified
4776004 – Lichen planus
Differential Diagnosis & PitfallsIn any location, consider drug-induced LP / lichenoid drug eruption. Characteristics of lichenoid drug reaction, as opposed to non-drug-associated LP, include older mean age, more generalized distribution, paucity of Wickham's striae, frequent photodistribution, sparing of mucous membranes, and distinct histologic characteristics.
Differential diagnosis of cutaneous LP:
- Subacute cutaneous lupus erythematosus
- Chronic graft-versus-host disease
- Granuloma annulare
- Pityriasis rosea
- Secondary syphilis (palm and sole lesions)
- Lichen simplex chronicus
- Prurigo nodularis
- Lichen amyloidosis
- Kaposi sarcoma
- Tinea corporis
- Lichen nitidus
- Lichen spinulosus
- Lichenoid keratosis
- Erythema dyschromicum perstans
- Mycosis fungoides
- Oral candidiasis
- Pemphigus vulgaris
- Seborrheic dermatitis (genital lesions)
- Lichen sclerosus (vulvar lesions)
- Recessive dystrophic epidermolysis bullosa (vulvar lesions)
- Junctional epidermolysis bullosa (vulvar lesions)
- Migratory glossitis (geographic tongue)
- Secondary syphilis
- Alopecia areata
- Seborrheic dermatitis
- Discoid lupus erythematosus
- Pseudopelade of Brocq
- Other scarring alopecias
- Alopecia areata, which has specific nail manifestations
Drug Reaction DataBelow is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.
Patient Information for Lichen planus in Adult
OverviewLichen planus (LP) is a rash that affects the skin and, less often, the scalp, fingernails, toenails, and/or inside the mouth or genital area (mucous membranes). Lichen planus can resolve on its own without treatment, or it can be persistent, even with aggressive treatment.
Who’s At RiskPeople of any age, race / ethnicity, and sex can have lichen planus. However, it is rarely seen in young children and older adults; it is most common in people aged 30-60.
Although the cause of lichen planus is unknown, some people with the condition also have hepatitis C, an infection of the liver.
People who take certain medications may develop drug-induced lichen planus. These medications include:
- High blood pressure (hypertension) medicines, including diuretics (eg, hydrochlorothiazide), ACE inhibitors (eg, lisinopril), and calcium channel blockers (eg, nifedipine).
- Diabetes medications, including sulfonylureas.
- NSAIDs such as ibuprofen (Advil, Motrin) and naproxen (Aleve).
- Antimalarial medications.
- Tumor necrosis factor (TNF)-alpha inhibitors.
- Tyrosine kinase inhibitors.
Signs & SymptomsThe most common locations for lichen planus include the:
- Inner wrists.
- Inner ankles.
- Lower legs.
- Fingernails and toenails.
New lesions of lichen planus can be caused by injury to the skin.
Once lichen planus lesions heal, they often leave behind patches of dark gray skin, which are more pronounced in darker skin colors. These areas may take months to return to their normal color.
In the mouth, lichen planus appears as white streaks or patches (flat, smooth areas that are larger than a thumbnail), most often seen on the inner cheeks. Oral lichen planus is usually not painful, but in severe cases, there may be painful sores in the mouth.
When lichen planus involves the fingernails or toenails, the nails may become thick, or they may have splitting, ridges, or grooves. In severe cases, the entire nail may be destroyed.
On the scalp, lichen planus (called lichen planopilaris) may cause skin color change, irritation, and, in some cases, permanent hair loss.
On the genitals, lichen planus lesions may be quite tender and sores may develop, especially in women.
- Apply over-the-counter hydrocortisone cream to help relieve skin itching in mild lichen planus.
- If you have lichen planus in the mouth, avoid drinking alcohol and using tobacco products.
When to Seek Medical CareIf you develop an itchy, bumpy rash, see a dermatologist or another medical professional for evaluation.
If you have severe oral lichen planus, there is a very small chance of developing oral cancer, so you should see your dentist twice a year to check for cancer.
TreatmentsYour medical professional will check your medication list to see if one of your medications may be the cause. If lichen planus is suspected, a dermatologist may want to perform a skin biopsy.
In addition, one of the following treatments may be recommended:
- Topical corticosteroid cream, lotion, ointment, or gel, eg, prednisone (Rayos), betamethasone (Diprolene, Celestone), triamcinolone (Aristospan, Kenalog), or Halobetasol (Ultravate, Halonate)
- Corticosteroids injected directly into any thick lesions
- Oral antihistamine pills such as loratadine (Claritin), cetirizine (Zyrtec), fexofenadine (Allegra), desloratadine (Clarinex), hydroxyzine (Vistaril), or diphenhydramine (Benadryl) for itching
- Ultraviolet light treatment
- Topical tacrolimus (Protopic) or pimecrolimus (Elidel)
- Topical corticosteroid mouthwash, ointment, or gel
- Pain-relieving mouthwash
- Oral medications, such as prednisone, metronidazole (Flagyl), isotretinoin (Amnesteem, Claravis), acitretin (Soriatane), and hydroxychloroquine (Plaquenil)
Lichen planus in AdultSee also in: Anogenital,Nail and Distal Digit