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LEARNING & DEVELOPMENT
CPD
Lichen planus and its management
In a recent letter to The Journal Christine Clark stated that pharmacists
should play a major role in the management of both long- and shortterm skin conditions but that research is needed to identify the types of
dermatological problems commonly presented. In this article she
describes lichen planus and how pharmacists can support sufferers
Reflect
Plan
Evaluate
©2006 Galderma S.A. All rights reserved
Act
Reflect on knowledge gaps
1. What is lichen planus?
2. How is it treated?
3. What advice can you give about
managing the condition?
Before reading on, think about how this
article may help you to do your job better.
ICHEN PLANUS (also known as
lichen ruber or lichen ruber planus)
— a non infectious condition
involving the skin or mucous membranes
— affects up to 2 per cent of people.
Although it is less well known than
psoriasis and eczema, the impact of lichen
planus can be significant. For example, it
has been shown that the condition has a
similar impact on the patient’s quality of
life to that of psoriasis1 and awareness of
the condition and the measures that can be
used to ameliorate it is important for
primary care health professionals.
L
Clinical presentation
Like psoriasis and eczema, lichen planus
can present in a number of clinical variants.
Typically, it appears as an itchy rash of
small (3 to 5mm diameter), shiny, raised,
reddish-purple (violaceous) papules. The
papules are flat topped and can be covered
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Lichen planus Typically presents as shiny raised red-purple papules
in a net-like pattern of white streaks known
as Wickham’s striae.
The rash appears suddenly, commonly
affecting the inside of the wrists, ankles,
elbows and lower back, although other
parts of the body can also be affected. It
can sometimes appear in lines where the
skin has been scratched or cut. The rash
usually lasts for several months and new
lesions can break out while others are
clearing. It can cause intense itching,
particularly at night. Thickened
(hypertrophic) lichen planus affects the
shins, and ring-shaped (annular) lichen
planus affects areas with creases in the
skin, such as the armpits.
About 50 per cent of people with lichen
planus affecting the skin also have oral
involvement. It is also possible to have oral
lichen planus — often diagnosed by dentists
— without the skin being affected. The
most frequently affected areas are the inside
of the cheeks and the sides of the tongue.
The affected mucosa is usually covered
with painless white streaks in a lace- or
fern-like pattern, but there is also an erosive
form of the condition in which painful,
persistent ulcers occur. Occasionally the
gums are affected and redness and peeling
occur. This is sometimes due to contact
allergy to mercury in amalgam fillings. In
such cases the lichen planus can resolve on
replacing the fillings with a mercury-free
alternative. (Contact allergy should be
confirmed by patch testing.)
Genitals can also be affected by lichen
planus. In men, it can present as purplecoloured or white ring-shaped patches on
the penis. These are not usually itchy. In
women, vulval lichen planus can range
from white-streaked papules to severe
erosions. Soreness, burning and rawness are
common symptoms in addition to itching
and pain on intercourse (dyspareunia).
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Panel 1: Advice on lichen planus
● Lichen planus is usually a self-limiting condition. There is a small likelihood of recurrence.
● Lichen planus is not contagious and cannot be passed by skin contact or sexual contact.
● There is no cure but treatment can control the condition (and may clear the skin lesions) until it
resolves.
● No large randomised controlled clinical trials have been conducted for therapy and several
treatments may need to be tried.
● Potent topical corticosteroids are a safe and appropriate treatment for lichen planus, even when
used on sensitive areas such as the genitals and flexures (eg, armpits).
● Postinflammatory hyperpigmentation is often an unavoidable effect of the disease; it is not
caused by topical corticosteroids.
symptoms as much as possible until there
is spontaneous remission — asymptomatic
lichen planus requires no treatment.
There are not many products licensed
specifically for lichen planus and
pharmacists are in a position to advise both
patients and prescribers on what
formulations are available. They are also in
a position to provide advice on potential
side effects of treatments and to give
reassurance, for example, where the
condition necessitates the use of a potent
steroid on genitals.
● Patients should take care to avoid skin damage because new lesions can appear at the sites of
scratches or cuts.
● Contact with soap, bubble bath, shampoos etc can further irritate the skin.
Reports suggest that more than 50 per cent
of women with oral lichen planus have
undiagnosed vulvar lichen planus.
It is estimated that 10 per cent of lichen
planus cases involve the nails.
Characteristic changes include longitudinal
grooving and ridging, darkening,
thickening and separation of the nail from
the nail bed (onycholysis). Lichen planus
occasionally appears on the scalp where it
can cause patchy scarring alopecia (ie, hair
loss can be permanent).
Lichen planus can occur at any age but
over two thirds of patients are aged
between 30 and 60 years. No racial trends
have been noted.
Causes
The cause is not well understood. Lichen
planus is thought to be the result of a cellmediated immune response to an induced
antigenic change in epidermal cells of a
genetically predisposed individual.
Autocytotoxic CD8+ T lymphocytes in
lesional skin recognise a major
histocompatibility class I antigen (lichen
planus specific antigen; LPSA). The exact
nature of this antigen is unknown — it
might be an autoreactive peptide or an
exogenous antigen such as a drug, contact
allergen or virus. The activated T
lymphocytes are believed to induce
apoptosis of basal keratinocytes.
An association between lichen planus and
hepatitis C has been reported and the onset or
worsening of the condition has been linked to
stressful life events. Some patients also have
a family history of lichen planus, which
might indicate a genetic predisposition. The
significance of these observations is not fully
understood. Drug-induced rashes that look
like lichen planus are described as
lichenoid drug eruptions. They are usually
pink or purple flat, scaly patches on the
trunk. This is a rare side effect of a number
of drugs including beta blockers, nonsteroidal anti-inflammatory drugs,
angiotensin-converting enzyme inhibitors,
sulphonylureas, gold, antimalarial agents,
penicillamine and thiazides. Some drugs,
such as quinine and thiazide diuretics, have
been implicated in causing actinic
(sunlight-activated) lichen planus in sunexposed sites. Lichenoid drug eruptions
clear up slowly after the responsible
medicine is discontinued.
Diagnosis
Lichen planus is diagnosed on the basis of
examination findings and history. Because
of the variable appearance of lichen planus
it can sometimes be confused with planar
warts, some types of eczema or psoriasis,
tinea corporis or pityriasis rosea. For this
reason many patients end up being referred
to a dermatologist. The possibility of a
lichenoid drug eruption also needs to be
excluded. Sometimes a biopsy, under local
anaesthetic, is taken to confirm the
diagnosis (there are characteristic
histological changes) and to exclude the
malignancy.
Cutaneous lichen planus Mild cases
may need treatment for itching — sedating
antihistamines can be taken at night to ease
itching and the resulting sleep disturbance
— and patients should also be given advice
about measures to prevent further damage
to inflamed skin, such as avoiding soap and
harsh detergents.
Moisturisers with a good lipid content
(so not aqueous cream) may soothe the
skin and also help to reduce itching.
However, moderate lichen planus affecting
the skin is usually treated with very potent
or potent topical corticosteroids such as
clobetasol and fluocinonide, which
combats both itching and inflammation. As
inflammation is suppressed the lesions will
change colour and flatten. Patients should
be advised that once the lesions have
changed from red-purple to grey or brown
and flattened there will be no further
response to the topical corticosteroid and
treatment should be discontinued. Such
treatment may be needed for up to six
weeks, even though it is with a high
potency steroid. It should also be noted that
topical steroids will not make any
postinflammatory hyperpigmentation
(brown or grey marks) disappear any faster
but will increase the risk of side effects
such as thinning of the skin. On the other
hand, patients are sometimes given the
impression that steroids are dangerous
Author Christine Clark will be
available to answer questions
online on the topic of this CPD
article until 28 June 2010
Management
There is no cure for lichen planus and the
objective of treatment is to suppress
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Panel 2: Advice for people with oral lichen planus
● Avoid eating spicy foods and anything
©2006 Galderma S.A. All rights reserved
acidic (eg, fruit juices, tomatoes,
strawberries).
● Avoid crispy foods (eg, crusty bread or
crisps.)
● Avoid drinking alcohol, particularly spirits.
● Try sticking to fairly bland food (eg,
porridge, softly boiled eggs, mashed
potatoes etc) when lesions are painful.
● If you cannot keep to your usual
toothpaste, try an alternative like Aloedent, which is mild and non-irritating.
● Keep your mouth as clean as possible but do not brush your teeth more than twice a day.
● If you wish to use a mouthwash choose one that does not contain alcohol (eg, Dentyl).
● Your dentist may want to see you every couple of months if you have erosive oral lichen planus
but be wary of dental hygienists using equipment to polish your teeth — this might cause
damage to your gums.
● Avoid smoking.
Adapted from the UKLP patient information leaflet
to use and pharmacists should try to avoid
inducing under-treatment. Sometimes
products with antibacterials (eg, Trimovate)
are prescribed but there does not seem to
be a rationale for the antibiotic component.
Severe lichen planus (ie, extensive or
painful and erosive disease and nail
destruction) can be treated with oral
corticosteroids (eg, oral prednisolone 20mg
daily for two to six weeks, followed by a
taper). Other treatments that have been
tried (unlicensed indications) include the
topical calcineurin inhibitors tacrolimus
and pimecrolimus, ciclosporin
(1–6mg/kg/day for several months2),
acitretin (30mg/day for eight weeks2) and
methotrexate (1–15mg/week for up to 17
months3). Treatment with ultraviolet light
(UVB, narrow band UVB and PUVA
[psoralen and UVA]) has also been used for
extensive cutaneous disease.
Oral lichen planus Consensus
guidelines published in 2005 recommend
that first-line treatment for oral lichen
planus should be with topical
corticosteroids.4 Agents, such as
betamethasone valerate, clobetasol,
fluocinolone acetonide, fluocinonide and
triamcinolone, formulated in adhesive paste
have been widely used. However, in the
UK, there is no longer a topical steroid
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proprietary product formulated in
carmellose gelatin paste (ie, Orabase).
The available topical steroid products for
use on the oral mucosa are hydrocortisone
oral mucosal tablets (pellets) and
betametasone 500μg soluble tablets
dissolved in 10–15 ml of water and used as
a mouthrinse up to three times a day
(unlicensed indication). Metered dose
inhalers (eg, beclometasone dipropionate
inhaler 100μg and fluticasone 50μg,
unlicensed indication) have also been used
as mouth sprays, sprayed three or four
times a day on affected sites.5
Fluorinated steroids (fluocinonide 0.05
per cent and fluocinolone acetonide 0.1 per
cent) have been found to be effective in the
treatment of severe oral lichen planus that
has failed to respond to other treatments.4
Systemic steroids are generally reserved
for disease that does not respond to topical
treatments. Other agents, such as
tacrolimus, retinoids and PUVA, are
reserved for third-line treatment.
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Mouthwashes can be helpful for a sore
mouth, particularly if used before meals.
Regular use of benzydamine hydrochloride
(0.15 per cent) spray or mouthrinse is an
option. If this is not effective 2 per cent
lidocaine gel may be applied to painful
areas. An antiseptic mouthwash or gel may
also be recommended, to help to control
dental plaque.
Genital lichen planus Genital disease
is also treated with very potent topical
corticosteroids, such as clobetasol
propionate 0.05 per cent.6 For example, the
dermatology department at Ninewells
Hospital, Dundee, prescribes Dermovate to
be applied daily for a month, then on
alternate days for a month and then twice a
week for a third month. Although data
sheets usually advise against the use of
such potent steroids on the genital area,
dermatologists agree that lichen planus is
one of the few conditions where it is not
only appropriate, but in the case of vulvar
disease, essential to avoid serious
destructive damage. (The summary of
product characteristics for Dermovate
contraindicates its use for “perianal and
genital pruritus” but dermatologists
emphasise that genital lichen planus is
more than “an itchy bottom”.)
Hydrocortisone acetate foam used
rectally to treat inflammatory bowel disease
can be used inside the vagina (unlicensed
indication). Steroid suppositories have also
been used vaginally. The treatment should
be used daily at bedtime for two or three
months and then twice a week. This helps
to prevent vaginal adhesions.6
One small study found that topical
pimecrolimus was well tolerated and
effective in most women with genital
lichen planus.7
Outcomes
In general, the prognosis for people with
lichen planus is good. Without treatment,
about 50 per cent of cases of cutaneous
lichen planus clear within nine months.
Most cases of cutaneous lichen planus
resolve spontaneously within 18 months
and usually do not recur. (It is reported that
about one in six patients will experience a
recurrence.) Oral disease and erosive
disease of the vulva or penis, however,
tend to be more persistent. Oral lichen
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Panel 3: Advice for people with genital lichen planus
● Wash with plain warm water (no soap or bubble bath) and use a soap substitute (eg, aqueous
©2006 Galderma S.A. All rights reserved
cream).
Lichen planus 10 per cent of cases involve nails
planus is reported to have an average
duration of five years but, according to the
British Dental Health Foundation, oral
lichen planus generally never goes away.
Residual skin marking (postinflammatory hyperpigmentation) can
persist for a long time and can be more
marked in Asian or Afro-Caribbean skin.
There is a small risk that long-standing
erosive lichen planus can undergo
cancerous changes resulting in oral or
genital tumours.
Role for pharmacists
In addition to giving advice on treatment,
pharmacists can:
● Explain what is known about lichen
planus (see Panel 1) and encourage
people to seek medical attention
● Advise on other measures that might help,
particularly for those with oral (see Panel
2) or genital lichen planus (see Panel 3)
● Signpost people to patient support groups.
● Wash your hair over a basin to avoid contact of shampoo with affected skin.
● Apply a plain emollient or aqueous cream liberally before and after urinating.
● Aqueous cream is more soothing if chilled before application.
● Ice packs (or a bag of frozen peas) can be useful to reduce itching and swelling but should not
be applied directly onto the skin (this can damage skin further).
● Use a good sexual lubricant (eg, Astroglide, V Gel and Sensilube). These products are mucuslike and moisturising.
● Women should wear stockings instead of tights.
● Go without underwear wherever possible.
Adapted from the UKLP patient information leaflet
efficacy.Archives of Dermatology
1998;134:1521–30.
3. Nylander Lundqvist E,Wahlin YB, Hofer PA.
Methotrexate supplemented with steroid ointments
for the treatment of severe erosive lichen ruber.Acta
Dermato Venereologica 2002;82:63–4.
4. Lodi G, Scully C, Carrozzo M, Griffiths M, Sugerman PB
and Hongprasom K. Current controversies in oral
lichen planus: Report of an international consensus
meeting. Part 2. Clinical management and malignant
transformation. Oral surgery, oral medicine, oral
pathology, oral radiology and endodontics
2005;100:164–78.
5. European Association of Oral Medicine. Oral lichen
planus. Available at www.eaom.net (accessed on
28 May 2010).
6. Lewis FM, Pelisse M.Vulvar lichen planus: clinical
aspects and guideline to management. CME
Journal of Gynecologic Oncology 2005;10:188–92.
7. Lonsdale-Eccles AA, Velangi S. Topical
pimecrolimus in the treatment of genital lichen
planus: a prospective case series. British Journal of
Dermatology 2005; 153:390–4.
Resources
Signposting
■ Useful information can be downloaded from the
UK Lichen Planus website (www.uklp.org.uk).The
organisation can also provide contact with other
people with lichen planus.
■ Patients with scalp disease can also be signposted
to Alopecia UK (www.alopeciaonline.org.uk),
which has a network of local groups in the UK.
References
1. Balci DD, Inandi T. Dermatology life quality index
scores in lichen planus: comparison of psoriasis and
healthy controls.Turkderm 2008; 42:127–30.
2. Cribier B, Frances C, Chosidow O.Treatment of lichen
planus: an evidence-based medicine analysis of
■ Information leaflets on lichen planus are available
from the British Association of Dermatologists and
from Clinical Knowledge Summaries.
Further reading
■ An article by Chuang T-Y, Stitle L. Lichen planus.
(http://emedicine.medscape.com) gives further
information on histological findings and doses of
third-line agents used. Further details on oral lichen
planus are also available at this site, in an article
authored by Sugerman P and Porter SR.
■ Chan ESY,Thornhill M, Zakrzewska JJM.
Interventions for treating oral lichen planus.
Cochrane Database of Systematic Reviews 1999,
Issue 2.Art. No.: CD001168.
● Christine Clark, PhD, FRPharmS, is a
medical writer and chairman of the Skin
Care Campaign.
CPD articles are commissioned by The
Pharmaceutical Journal and are not peer
reviewed.
Act: practice points
Reading is only one way to undertake CPD
and the Society will expect to see various
approaches in a pharmacist’s CPD portfolio.
1. Review your counselling related to
supplies of topical steroids.
2. Speak to your local dentist about oral
lichen planus and his or her
formulations of choice.
3. Are you taking appropriate action
when supplying medicine for an
unlicensed indication? Download
“Fact sheet: five” the Royal
Pharmaceutical Society legal and
ethical advisory service’s
guidance from the Society’s
website.
Evaluate
For your work to be presented as CPD, you
need to evaluate your reading and any
other activities. What have you learnt?
How has it added value to your practice?
(Have you applied this learning or had any
feedback?) What will you do now and how
will this be achieved?
Record
Consider making this activity one of your
nine CPD entries this year.
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