Lichen planus in Child
See also in: Anogenital,Nail and Distal DigitAlerts and Notices
Synopsis
Childhood LP has been described after hepatitis B vaccination. Drugs causing LP-like eruptions (lichenoid drug reactions) include antihypertensives (ACE inhibitors: captopril and enalapril; beta blockers: propranolol and labetalol), thiazide diuretics, antimalarials (quinidine and hydroxychloroquine), penicillamine, NSAIDs, griseofulvin, tetracycline, antiepileptics, and many other drugs.
LP usually affects the glabrous (non-hair-bearing) skin and sometimes the mucosa, scalp, and nails. (See oral lichen planus for oral mucosal presentation and see lichen planopilaris for scalp presentation.) The frequency of childhood LP varies from 2.1%-11.2% of all cases of LP.
The majority of children who develop LP develop the classic form. Other variants include actinic, hypertrophic, linear, eruptive, follicular, atrophic, and bullous lesions.
LP may resolve spontaneously over several months. However, the disease generally has a chronic course with frequent remissions and exacerbations.
Codes
ICD10CM:L43.9 – Lichen planus, unspecified
SNOMEDCT:
4776004 – Lichen planus
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Diagnostic Pearls
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Differential Diagnosis & Pitfalls
- Psoriasis – Well-demarcated erythematous papules and plaques (on trauma-prone areas such as knees, elbows, and scalp) covered with silvery scale.
- Lichen nitidus – Small, pinpoint, monomorphic, skin-colored, round or dome-shaped papules in clusters. Common sites include the forearms, trunk, abdomen, and genitalia.
- Lichen striatus – Linear arrangement of hypopigmented or hyperpigmented inflammatory, lichenoid to eczematous papules on the extremities. No Wickham's striae or violaceous hue. Much less pruritus than lichen planus.
- Pityriasis lichenoides chronica – Small, ovoid, pink-brown papules covered with thin scale and crust that resolve with hypopigmentation.
- Granuloma annulare – Skin-colored beaded dermal papules in an annular pattern (hands and feet). No surface changes.
- Sarcoidosis – Erythematous to violaceous edematous dermal papules and plaques (face, extremities). No surface changes. Associated lymphadenopathy, uveitis, and chest symptoms.
- Lichenoid drug eruption – May appear more eczematous or psoriasiform than classic LP. Unlike exanthematous drug eruptions, lichenoid drug eruptions can occur several months to years after the drug is started.
- Papular epidermal nevus with "skyline" basal cell layer (PENS) is a rare, newly described entity where affected children develop few hyperkeratotic polygonal or rectangular papules in one or more body locations. PENS syndrome describes a subset of patients with PENS with associated neurological findings such as epilepsy or neurodevelopmental delay.
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Management Pearls
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Therapy
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Drug Reaction Data
Below 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.Subscription Required
References
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Last Reviewed:05/06/2019
Last Updated:10/09/2019
Last Updated:10/09/2019
Patient Information for Lichen planus in Child
Overview
Lichen 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 Risk
People 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.
- Penicillamine.
- Tumor necrosis factor (TNF)-alpha inhibitors.
- Tyrosine kinase inhibitors.
Signs & Symptoms
The most common locations for lichen planus include the:- Inner wrists.
- Forearms.
- Inner ankles.
- Lower legs.
- Neck.
- Trunk.
- Mouth.
- Fingernails and toenails.
- Scalp.
- Genitals.
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.
Self-Care Guidelines
- 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 Care
If 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.
Treatments
Your 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 Child
See also in: Anogenital,Nail and Distal Digit