John R. Tkach, M.D.
300 North Willson, Suite 203B
Bozeman, MT 59715
(406) 587-5442

Lichen Planus

Patient Information Sheet

When I die and go to Heaven, my first question is going to be, "What was the cause of lichen planus?" Because we sure don't know now. It is not a bad or dangerous thing to have. It is a nuisance.

Lichen planus is a rash that classically appears as small red to purple 3-6 mm flat topped, raised plaques. It can occur anywhere, but the most common area is on the wrists. A third of cases arise in the mouth as white lace like lines along the inside of the cheeks where the bite line is. I also see that as an isolated event on the lower lip.

Part of the reason for confusion is that lichen planus can take on 8 forms or more:

  1. Hypertrophic Lichen Planus
  2. Atrophic Lichen Planus
  3. Vesiculobullous (blisters)
  4. Ulcerative Lichen Planus
  5. Follicular Lichen Planus
  6. Actinic Lichen Planus
  7. Lichen planus pigmentosa
  8. Lichen Planus of the nails

The major features of lichen planus are:

  1. Purple, itchy, polygonal papules and plaques
  2. Wickham's striae- little white lines on top of the plaques
  3. Koebnerization- small injuries heal leaving behind lichen planus lesions instead of normal skin.

In my experience, when lichen planus appears, it tends to go one for at least 6 months. Individual spots come and go, but the whole process lingers. Getting lichen planus is not your fault. You did not do anything wrong. You won't give it to others. It is not contagious.

Koebnerization is one of the most helpful clues. Minor injuries heal leaving lichen planus behind. Often these lesions are linear. There is a line or streak of lichen planus papules. That's a pretty good sign of lichen planus.

Lichenoid Drug Eruptions

The following drugs can cause lichen planus like rashes: Amlodipine, antimalarials, beta-blockers, captopril, diflunisal, diltiazem, enalapril, furosemide, glimepiride, gold, leflunomide, levamisole, L-thyroxine, orlistat, penicillamine, phenothiazine, pravastatin, proton pump inhibitors, rofecoxib, salsalate, sildenafil, tetracycline, thiazides, and ursodeoxycholic acid.

The drug eruptions look different on biopsy from true lichen planus. Both show a band of lymphocytes hugging the underside of the epidermis. True lichen planus shows no retained nuclei in the outer dead layer of skin (orthokeratosis). In lichenoid drug eruptions, there are nuclei retained the dead layer (parakeratosis). The implication is that, if you have a drug induced lichen planus, you need to identify the drug and stop it.

I have not seen it since the 1970's, but some people broke out in lichen planus where drops of a color film developer got on their skin.

Treatment:

The treatment is the use of some form of cortisone such as cortisone creams or ointments. Cortisone pills work, but I prefer to avoid that unless the lichen planus is very wide spread. The most reliable treatment is for me to take a small needle and inject a very small amount of very dilute cortisone (intralesional Kenalog) right into the plaques. Sunlight and topically applied tar oils like Balnetar often help lichen planus.

For the mouth inside the cheeks, intralesional Kenalog is the best treatment, but topical Lidex Gel (fluocinonide) often works very well.

For the drug reaction form of lichen planus, just stopping the offending drug may be enough to clear it up. A topical cortisone ointment like Lidex (fluocinonide) will speed up healing.

The information provided in these patient information sheets is offered for general informational and educational purposes only; it is not offered as and does not constitute medical advice. In no way are any of the materials presented meant to be a substitute for professional medical care or attention by a qualified practitioner, nor should they be construed as such.

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