Lichen planus

Lichen planus

Lichen planus affecting the shins.
Classification and external resources
Specialty Dermatology
ICD-10 L43
ICD-9-CM 697.0
DiseasesDB 7452
MedlinePlus 000867
eMedicine derm/233 derm/663
Patient UK Lichen planus
MeSH D008010, D017676

Lichen planus (LP) is a disease of the skin and/or mucous membranes that resembles lichen. The cause is unknown, but it is thought to be the result of an autoimmune process with an unknown initial trigger. There is no cure, but many different medications and procedures have been used to control the symptoms.

The term lichenoid reaction (or lichenoid lesion) refers to a lesion of similar or identical histopathologic and clinical appearance to lichen planus (i.e. an area which looks the same as lichen planus, both to the naked eye and under a microscope).[1][2] Sometimes dental materials or certain medications can cause a lichenoid reaction.[1] They can also occur in association with graft versus host disease.[1][3]:258

Classification

Lichen planus has been described as an autoimmune disease,[4] a dermatosis,[5] a papulosquamous disorder, a mucocutaneous disease,[6] and an inflammatory disease.[7]

Lichen planus lesions are so called because of their "lichen-like" appearance[8] and can be classified by the site they involve, or by their morphology.

Site

Lichen planus may be categorized as affecting mucosal or cutaneous surfaces.

Pattern

Lichen planus lesions can occur in many different forms:

Lesion morphology Description[12][13]
Annular 'Ring-shaped' lesions that develop gradually from single small pigmented spots into circular groups of papules with clear, unaffected skin in the center. Annular lesions occur in approximately ten percent of lichen planus cases. The ring-like lesions may very slowly enlarge, co-join and morph into larger irregular (serpentine) bands, sometimes accompanied by lines (See Linear, below).
Linear Papules are arranged in a line (the "Blaschko line").[14] This pattern may develop secondary to trauma (koebnerization) or, uncommonly, as a spontaneous, isolated eruption, usually on the extremities, and rarely on the face.[15]
Hypertrophic This pattern usually occurs on the extremities, especially the shins and the interphalangeal joints, and tends to be the most pruritic variant of lichen planus. Also known as "Lichen planus verrucosus".
Atrophic This morphology is characterized by the presence of a few well-demarcated, white-bluish papules or plaques with central superficial atrophy. This is a rare variant of lichen planus.
Bullous This morphology is characterized by the development of vesicles and bullae with the skin lesions. This is a rare variant of lichen planus, and also known as "Vesiculobullous lichen planus".
Ulcerative This morphology is characterized by chronic, painful bullae and ulceration of the feet, often with cicatricial sequelae evident. This is a rare variant of lichen planus.
Pigmented This morphology is characterized by hyperpigmented, dark-brown macules in sun-exposed areas and flexural folds. This is a rare variant of lichen planus.

Overlap syndromes

Occasionally, lichen planus is known to occur with other conditions. For example:

Signs and symptoms

Lichen planus affecting the lower lip.

Although lichen planus can present with a variety of lesions, the most common presentation is as a well-defined area of purple-coloured, itchy, flat-topped papules with interspersed lacy white lines (Wickham's striae). This description is known as the characteristic "6 Ps" of lichen planus: planar (flat-topped), purple, polygonal, pruritic, papules, and plaques.[9] This rash, after regressing, is likely to leave an area of hyperpigmentation that slowly fades. That said, a variety of other lesions can also occur.[8]

Cutaneous lichen planus

Cutaneous lichen planus on the shin.
Lichen planus involving the nails.

Variants of cutaneous lichen planus are distinguished based upon the appearance of the lesions and/or their distribution.[18] Lesions can affect the:

Other variants may include:

Mucosal lichen planus

Lichen planus on the lips and the lateral border of the tongue

Lichen planus affecting mucosal surfaces may have one lesion or be multifocal.[30] Examples of lichen planus affecting mucosal surfaces include:[30]

Oral lichen planus

Oral lichen planus (also termed oral mucosal lichen planus),[35] is a form of mucosal lichen planus, where lichen planus involves the oral mucosa, the lining of the mouth. This may occur in combination with other variants of lichen planus.[36] Six clinical forms of oral lichen planus are recognized:[36]

These types often coexist in the same individual. Oral lichen planus tends to present bilaterally as mostly white lesions on the inner cheek,[4] although any mucosal site in the mouth may be involved. Other sites, in decreasing order of frequency, may include the tongue, lips, gingivae, floor of the mouth, and very rarely, the palate.[4]

Generally, oral lichen planus tends not to cause any discomfort or pain, although some people may experience soreness when eating or drinking acidic or spicy foodstuffs or beverages.[36] When symptoms arise, they are most commonly associated with the atrophic and ulcerative subtypes. These symptoms can include a burning sensation to severe pain.[4]

Causes

The cause of lichen planus is unknown,[8][34][37] but it is not contagious and does not involve any known pathogen.[38] It is thought to be a T cell mediated autoimmune reaction (where the body's immune system targets its own tissues).[4] This autoimmune process triggers apoptosis of the epithelial cells.[4] Several cytokines are involved in lichen planus, including tumor necrosis factor alpha, interferon gamma, interleukin-1 alpha, interleukin 6, and interleukin 8.[4] This autoimmune, T cell mediated, process is thought to be in response to some antigenic change in the oral mucosa, but a specific antigen has not been identified.[4]

Where a causal or triggering agent is identified, this is termed a lichenoid reaction rather than lichen planus. These may include:[11]

It has been suggested that lichen planus may respond to stress, where lesions may present during times of stress. Lichen planus can be part of Grinspan's syndrome.

It has also been suggested that mercury exposure may contribute to lichen planus.[40]

Diagnosis

Lichen planus lesions are diagnosed clinically by their "lichen-like" appearance.[8] A biopsy can be used to rule out conditions that may resemble lichen planus, and can pick up any secondary malignancies.[41]

Histopathology

Micrograph of lichen planus. H&E stain.

Lichen planus has a unique microscopic appearance that is similar between cutaneous, mucosal and oral. A Periodic acid-Schiff stain of the biopsy may be used to visualise the specimen. Histological features seen include:[42]

Differential diagnosis

The differential diagnosis for OLP includes:

Treatment

There is no cure for lichen planus,[4] and so treatment of cutaneous and oral lichen planus is for symptomatic relief or due to cosmetic concerns.[4][8][41] When medical treatment is pursued, first-line treatment typically involves corticosteroids,[8] and removal of any triggers.[39] Without treatment, most lesions will spontaneously resolve within 6–9 months for cutaneous lesions,[8] and longer for mucosal lesions [42]

Cutaneous lichen planus

Many different treatments have been reported for cutaneous lichen planus, however there is a general lack of evidence of efficacy for any treatment.[14][44] Treatments tend to be prolonged, partially effective and disappointing.[14] First-line treatments may include retinoids such as Acitretin, or corticosteroids [8][14][44]

A variety of other therapies are also used if these are unsuccessful. These include oral corticosteroids, vitamin D3 analogues, antibiotics such as Dapsone, hydroxychloroquine and Cyclosporin, some anti-coagulants, and psoralen plus ultraviolet-A.[8][14][44]

Cosmetic treatments may include laser surgery, cryotherapy, and phototherapy.[14][44]

Oral lichen planus

Reassurance that the condition is benign, elimination of precipitating factors and improving oral hygiene are considered initial management for symptomatic OLP, and these measures are reported to be useful.[4] Treatment usually involves topical corticosteroids (such as betamethasone, clobetasol, dexamethasone, and triamcinolone) and analgesics, or if these are ineffective and the condition is severe, the systemic corticosteroids may be used. Calcineurin inhibitors (such as pimecrolimus, tacrolimus) or cyclosporin) are sometimes used.[4]

Prognosis

In contrast to cutaneous lichen planus, lichen planus lesions in the mouth may persist for many years,[41] and tend to be difficult to treat, with relapses being common.[34] Atrophic/erosive lichen planus is associated with a small risk of malignant transformation,[41] and so people with OLP tend to be kept on long term review to detect any potential change early. Sometimes OLP can become secondarily infected with Candida organisms.

Epidemiology

The overall prevalence of lichen planus in the general population is about 0.1 - 4%.[9] It generally occurs more commonly in females, in a ratio of 3:2, and most cases are diagnosed between the ages of 30 and 60, but it can occur at any age.[9][45]

Oral lichen planus is relatively common,[34] It is one of the most common mucosal diseases. The prevalence in the general population is about 1.27-2.0%,[4][41] and it occurs more commonly middle aged people.[4] OLP in children is rare. About 50% of females with oral lichen planus were reported to have undiagnosed vulvar lichen planus.[9]

History

Lichen planus was first reported in 1869 by Erasmus Wilson.[42]

Notes

  1. ↑ Cutaneous lichen planus affecting the extremities is also known as "Lichen planus actinicus", "Actinic lichen niditus," "Lichen planus atrophicus annularis," "Lichen planus subtropicus," "Lichen planus tropicus," "Lichenoid melanodermatitis," and "Summertime actinic lichenoid eruption"

References

  1. 1 2 3 Greenberg MS, Glick M, Ship JA (2008). Burket's oral medicine (11th ed.). Hamilton, Ont.: BC Decker. pp. 89–97. ISBN 9781550093452.
  2. ↑ Lewis MAO, Jordan RCK (2012). Oral medicine (2nd ed.). London: Manson Publishing. pp. 66–72. ISBN 9781840761818.
  3. ↑ Barnes L (editor) (2009). Surgical pathology of the head and neck (3rd ed.). New York: Informa healthcare. ISBN 9781420091632.
  4. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Thongprasom, K; Carrozzo, M; Furness, S; Lodi, G (Jul 6, 2011). "Interventions for treating oral lichen planus.". The Cochrane database of systematic reviews (7): CD001168. doi:10.1002/14651858.CD001168.pub2. PMID 21735381.
  5. 1 2 Asch, S; Goldenberg, G (March 2011). "Systemic treatment of cutaneous lichen planus: an update.". Cutis; cutaneous medicine for the practitioner 87 (3): 129–34. PMID 21488570.
  6. 1 2 Sharma, A; Białynicki-Birula, R; Schwartz, RA; Janniger, CK (July 2012). "Lichen planus: an update and review.". Cutis; cutaneous medicine for the practitioner 90 (1): 17–23. PMID 22908728.
  7. 1 2 Cheng, S; Kirtschig, G; Cooper, S; Thornhill, M; Leonardi-Bee, J; Murphy, R (Feb 15, 2012). "Interventions for erosive lichen planus affecting mucosal sites.". The Cochrane database of systematic reviews 2: CD008092. doi:10.1002/14651858.CD008092.pub2. PMID 22336835.
  8. 1 2 3 4 5 6 7 8 9 Limited, Therapeutic Guidelines (2009). Therapeutic guidelines. (Version 3. ed.). North Melbourne, Vic.: Therapeutic Guidelines. pp. 254–255, 302. ISBN 978-0-9804764-3-9.
  9. 1 2 3 4 5 6 7 8 9 Usatine, RP; Tinitigan, M (Jul 1, 2011). "Diagnosis and treatment of lichen planus". American family physician 84 (1): 53–60. PMID 21766756.
  10. 1 2 Yamada T, Alpers DH; et al. (2009). Textbook of gastroenterology (5th ed.). Chichester, West Sussex: Blackwell Pub. p. 3304. ISBN 978-1-4051-6911-0.
  11. 1 2 Treister NS, Bruch JM (2010). Clinical oral medicine and pathology. New York: Humana Press. pp. 59–62. ISBN 978-1-60327-519-4.
  12. ↑ Freedberg, Irwin M., ed. (2003). Fitzpatrick's dermatology in general medicine (6th ed.). New York, NY: McGraw-Hill. pp. 465–8. ISBN 0-07-138076-0.
  13. 1 2 James, William D.; Elston, Dirk M.; Berger, Timothy G. Andrews' Diseases of the skin : clinical dermatology (11th ed.). London: Saunders/ Elsevier. pp. 219–24. ISBN 1-4377-0314-3.
  14. 1 2 3 4 5 6 Gorouhi, F; Firooz A; Khatami A; Ladoyanni E; Bouzari N; Kamangar F; Gill JK (2009). "Interventions for cutaneous lichen planus". Cochrane Database of Systematic Reviews (4). doi:10.1002/14651858.CD008038.
  15. 1 2 3 4 5 6 7 8 9 Bolognia, Jean L.; Jorizzo, Joseph L.; Rapini, Ronald P., eds. (2008). Dermatology (2nd ed.). St. Louis: Mosby/Elsevier. ISBN 1-4160-2999-0.
  16. ↑ Freedberg, Irwin M., ed. (2003). Fitzpatrick's dermatology in general medicine (6th ed.). New York, NY: McGraw-Hill. pp. 366, 470–1. ISBN 0-07-138076-0.
  17. 1 2 James, William D.; Elston, Dirk M.; Berger, Timothy G. Andrews' Diseases of the skin : clinical dermatology (11th ed.). London: Saunders/ Elsevier. p. 220. ISBN 1-4377-0314-3.
  18. ↑ Freedberg, Irwin M., ed. (2003). Fitzpatrick's dermatology in general medicine (6th ed.). New York, NY: McGraw-Hill. p. 466. ISBN 0-07-138076-0.
  19. ↑ Freedberg, Irwin M., ed. (2003). Fitzpatrick's dermatology in general medicine (6th ed.). New York, NY: McGraw-Hill. p. 468. ISBN 0-07-138076-0.
  20. 1 2 James, William D.; Elston, Dirk M.; Berger, Timothy G. Andrews' Diseases of the skin : clinical dermatology (11th ed.). London: Saunders/ Elsevier. p. 223. ISBN 1-4377-0314-3.
  21. 1 2 Gordon, KA; Vega, JM; Tosti, A (Nov–Dec 2011). "Trachyonychia: a comprehensive review". Indian journal of dermatology, venereology and leprology 77 (6): 640–5. doi:10.4103/0378-6323.86470. PMID 22016269.
  22. ↑ James, William D.; Elston, Dirk M.; Berger, Timothy G. Andrews' Diseases of the skin : clinical dermatology (11th ed.). London: Saunders/ Elsevier. p. 781. ISBN 1-4377-0314-3.
  23. ↑ Freedberg, Irwin M., ed. (2003). Fitzpatrick's dermatology in general medicine (6th ed.). New York, NY: McGraw-Hill. p. 467. ISBN 0-07-138076-0.
  24. ↑ Cevasco NC, Bergfeld WF, Remzi BK, de Knott HR (2007). "A case-series of 29 patients with lichen planopilaris: the Cleveland Clinic Foundation experience on evaluation, diagnosis, and treatment". J. Am. Acad. Dermatol. 57 (1): 47–53. doi:10.1016/j.jaad.2007.01.011. PMID 17467854.
  25. ↑ Freedberg, Irwin M., ed. (2003). Fitzpatrick's dermatology in general medicine (6th ed.). New York, NY: McGraw-Hill. p. 471. ISBN 0-07-138076-0.
  26. ↑ Freedberg, Irwin M., ed. (2003). Fitzpatrick's dermatology in general medicine (6th ed.). New York, NY: McGraw-Hill. p. 472. ISBN 0-07-138076-0.
  27. ↑ James, William D.; Elston, Dirk M.; Berger, Timothy G. Andrews' Diseases of the skin : clinical dermatology (11th ed.). London: Saunders/ Elsevier. p. 224. ISBN 1-4377-0314-3.
  28. 1 2 Freedberg, Irwin M., ed. (2003). Fitzpatrick's dermatology in general medicine (6th ed.). New York, NY: McGraw-Hill. p. 473. ISBN 0-07-138076-0.
  29. ↑ James, William D.; Elston, Dirk M.; Berger, Timothy G. Andrews' Diseases of the skin : clinical dermatology (11th ed.). London: Saunders/ Elsevier. p. 639. ISBN 1-4377-0314-3.
  30. 1 2 Ebrahimi, M; Lundqvist, L; Wahlin, YB; Nylander, E (October 2012). "Mucosal lichen planus, a systemic disease requiring multidisciplinary care: a cross-sectional clinical review from a multidisciplinary perspective". Journal of lower genital tract disease 16 (4): 377–80. doi:10.1097/LGT.0b013e318247a907. PMID 22622344.
  31. ↑ Chandan, VS; Murray, JA; Abraham, SC (June 2008). "Esophageal lichen planus". Archives of pathology & laboratory medicine 132 (6): 1026–9. doi:10.1043/1543-2165(2008)132[1026:ELP]2.0.CO;2. PMID 18517264.
  32. ↑ Panagiotopoulou, N; Wong, CS; Winter-Roach, B (April 2010). "Vulvovaginal-gingival syndrome.". Journal of obstetrics and gynaecology : the journal of the Institute of Obstetrics and Gynaecology 30 (3): 226–30. doi:10.3109/01443610903477572. PMID 20373919.
  33. ↑ Schlosser, BJ (May–Jun 2010). "Lichen planus and lichenoid reactions of the oral mucosa.". Dermatologic therapy 23 (3): 251–67. doi:10.1111/j.1529-8019.2010.01322.x. PMID 20597944.
  34. 1 2 3 4 Nico, MM; Fernandes, JD; Lourenço, SV (Jul–Aug 2011). "Oral lichen planus.". Anais brasileiros de dermatologia 86 (4): 633–41; quiz 642–3. PMID 21987126.
  35. ↑ Alam, F; Hamburger, J (May 2001). "Oral mucosal lichen planus in children.". International journal of paediatric dentistry / the British Paedodontic Society [and] the International Association of Dentistry for Children 11 (3): 209–14. PMID 11484471.
  36. 1 2 3 4 5 6 7 Scully C (2008). Oral and maxillofacial medicine : the basis of diagnosis and treatment (3rd ed.). Edinburgh: Churchill Livingstone. pp. 192–199. ISBN 9780702049484.
  37. ↑ Roopashree, MR; Gondhalekar, RV; Shashikanth, MC; George, J; Thippeswamy, SH; Shukla, A (November 2010). "Pathogenesis of oral lichen planus--a review.". Journal of oral pathology & medicine : official publication of the International Association of Oral Pathologists and the American Academy of Oral Pathology 39 (10): 729–34. doi:10.1111/j.1600-0714.2010.00946.x. PMID 20923445.
  38. 1 2 3 4 Davidson's principles and practice of medicine. (21st ed.). Edinburgh: Churchill Livingstone/Elsevier. 2010. pp. 1265–1266. ISBN 978-0-7020-3085-7. |first1= missing |last1= in Authors list (help)
  39. 1 2 Issa, Y; Brunton, PA; Glenny, AM; Duxbury, AJ (November 2004). "Healing of oral lichenoid lesions after replacing amalgam restorations: a systematic review.". Oral surgery, oral medicine, oral pathology, oral radiology, and endodontics 98 (5): 553–65. doi:10.1016/j.tripleo.2003.12.027. PMID 15529127.
  40. ↑ Dunsche A, Frank MP, Lüttges J, et al. (April 2003). "Lichenoid reactions of murine mucosa associated with amalgam". The British Journal of Dermatology 148 (4): 741–8. doi:10.1046/j.1365-2133.2003.05229.x. PMID 12752133.
  41. 1 2 3 4 5 Kerawala C, Newlands C, ed. (2010). Oral and maxillofacial surgery. Oxford: Oxford University Press. pp. 412–413. ISBN 978-0-19-920483-0.
  42. 1 2 3 Scully, C.; El-Kom, M. (1 July 1985). "Lichen planus: review and update on pathogenesis". Journal of Oral Pathology and Medicine 14 (6): 431–458. doi:10.1111/j.1600-0714.1985.tb00516.x.
  43. ↑ Odell EW (Editor) (2010). Clinical problem solving in dentistry (3rd ed.). Edinburgh: Churchill Livingstone. pp. 159–162, 192. ISBN 9780443067846.
  44. 1 2 3 4 Cribier, B; Frances, C; Chosidow, O (December 1998). "Treatment of lichen planus. An evidence-based medicine analysis of efficacy.". Archives of dermatology 134 (12): 1521–30. doi:10.1001/archderm.134.12.1521. PMID 9875189.
  45. ↑ Yu TC, Kelly SC, Weinberg JM, Scheinfeld NS (March 2003). "Isolated lichen planus of the lower lip". Cutis 71 (3): 210–2. PMID 12661749.

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