Cutaneous Lichen Planus

Aka: Cutaneous Lichen Planus, Lichen Planus

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II. Epidemiology

  1. Prevalence: 0.1-4% in United States
  2. Age usually 30-60 years
  3. Gender predominance: Slightly more common in women (especilly Perimenopause)

III. Pathophysiology

  1. Autoimmune mediated apoptosis of epithelial cells
  2. Involves CD8+ Cytotoxic T-Cells

IV. Associated Conditions

  1. Hepatitis C

V. Signs: General

  1. Characteristics
    1. Classic 6Ps
      1. Planar (flat topped lesions)
      2. Purple
      3. Polygonal
      4. Pruritic
      5. Papules
      6. Plaques
    2. Wickham Striae
      1. Lacy, reticular white lines covering the lesions
    3. Koebner Phenomenon
      1. May form in lines related to scratching
    4. Postinflammatory Hyperpigmentation
      1. May occur with lesion resolution (especially in dark skin)
  2. Distribution
    1. Cutaneous lesions form on flexor surfaces of wrists, Forearms, legs
    2. Oral Lichen Planus (25%)
    3. Genitalia
      1. Glans penis with annular pattern (see below)
      2. Vulvar Lichen Planus
    4. Scalp Lichen Planus
      1. Scaly pruritic Papules
      2. May progress to scarring Alopecia
    5. Nail Lichen Planus
      1. Irregular longitudinal grooves or ridges in the nail plate
      2. Subungual keratosis or Hyperpigmentation

VI. Types: Variants

  1. Annular Lichen Planus (10%)
    1. See Annular Lesions
    2. Rings of clustered lesions with central clearing
    3. May also form on penis and Buccal mucosa
  2. Atrophic Lichen Planus (rare)
    1. Patches or Plaques with superficial atrophy of variable coloration
  3. Hypertrophic Lichen Planus
    1. Forms on extensor surfaces (ankles, shins, PIP and DIP joint)
    2. Very pruritic
    3. Chronic with prominent scarring
  4. Vesiculobullous Lichen Planus
    1. Classic Lichen Planus lesions form bullae or vessicles
    2. Typically on mouth, back, buttocks, or legs
  5. Linear Lichen Planus (<1%)
    1. Unilateral pruritic, purple, flat-topped Papules in a linear pattern on the extremities

VII. Diagnosis

  1. Classic polygonal lesions on the flexor surfaces may not require biopsy for diagnosis
  2. Biopsy findings
    1. Epidermal hyperplasia with saw pattern
    2. Hyperparakeratosis with granular cell layer thickening
    3. Basal layer with vacuolar alteration
    4. T-Cell infiltration of the dermal-epidermal junction

VIII. Differential Diagnosis

  1. Eczema
  2. Lichen Simplex Chronicus
  3. Prurigo Nodularis
  4. Psoriasis
  5. Variants
    1. See Annular Lesion
    2. See Vesiculobullous

IX. Evaluation

  1. Liver Function Tests
  2. Hepatitis C Antibody

X. Management: Cutaneous Lichen Planus

  1. See Oral Lichen Planus
  2. See Vulvar Lichen Planus
  3. See Pruritus Management
  4. Cutaneous Lichen Planus (non-genital)
    1. High potency Topical Corticosteroids
    2. Consider topical Calcineurin Inhibitors if refractory to Topical Corticosteroids
  5. Severe, diffuse Cutaneous Lichen Planus
    1. Prednisone 30-60 mg orally daily for 3-6 weeks and then taper over an additional 4-6 weeks
    2. Phototherapy (narrow band UVB) for 30-40 minutes each of 2-3 days per week

XI. Course

  1. Isolated skin lesions without mucosal lesions may resolve spontaneously within 1 to 2 years

XII. References

  1. Usatine (2011) Am Fam Physician 84(1):53-60 [PubMed]

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