Lichen planus Treatment and Cure

Lichen planus can lead to a build-up of scale and scarring of the scalp.

Lichen planus is a pruritic inflammatory dermatosis that is commonly associated with mucosal involvement and rarely with nail dystrophy and scarring alopecia.

Oral lichen planus presents as white striae. Malignant tumours of the mouth account for 1% of all malignant tumours.

Aetiological agents include tobacco, heavy alcohol consumption and the areca nut. Intra-oral lesions which undergo malignant transformation include leucoplakia, lichen planus , submucous fibrosis and erythroplakia (a red patch). The previous male predominance has declined. Treatment is by surgical excision and/or radiotherapy.

Cause of Lichen planus

The cause is unknown but it has been postulated that a T-cell driven immune mechanism is involved. This stems from the fact that an almost identical rash can be caused by certain drugs (e.g. gold, levamisole, penicillamine or antimalarials) or by graft-versus-host disease.

Lichen planus Pathology

A mixed lymphohistiocytic infiltrate is seen at the dermoepidermal junction, which becomes ragged and saw-toothed. The basal layer shows liquefactive degeneration with the production of colloid bodies in the upper dermis. There may be acanthosis and a hyperkeratosis of the epidermis.

Clinical features of Lichen planus

The rash is characterized by small, purple flat-topped, polygonal papules that are intensely pruritic. It is common on the flexors of the wrists and the lower legs but can occur anywhere. There may be a fine lacy white pattern on the surface of lesions (Wickham's striae). Lesions may fuse into plaques, especially on the lower legs and in black Africans. Hyperpigmentation is common after resolution of lesions, especially in patients with pigmented skin.

Atrophic, hypertrophic and annular variants can occur. Lichen planus lesions often localize to scratch marks. If lesions occur in the scalp, they may cause a scarring alopecia.

Mucosal involvement is common. The mouth is the most commonly affected but the anogenital region, and rarely the oesophagus, can be involved. It can present as lacy white streaks, white plaques or as ulceration.

The prominent mucosal symptom is of pain rather than itch. Nails may be dystrophic and can be lost altogether (with scarring and 'wing' formation) in severe disease.

Prognosis of Lichen planus

The condition often clears by 18 months but can recur at intervals. The hypertrophic and atrophic variants, and mucosal disease are more persistent, lasting years. Ulcerative mucosal disease is premalignant.

Treatment of Lichen planus

This requires the use of potent topical steroids (0.05% clobetasol proprionate) and occasionally oral prednisolone (30 mg daily for 2-4 weeks). Occlusion of topical treatments can be helpful. Resistant cases may respond to PUVA, oral retinoids (0.5 mg/kg/day) or azathioprine (1-2 mg/kg/day).

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