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| ==Background==
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| *Uncommon disorder of unknown cause
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| *Estimated < 1% occurrence rate, most frequently 30 to 60 years of age
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| *Proposed immune-mediated mechanism, T cells (primarily CD8+) activated against basal keratinocytes
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| **HCV association is controversial
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| *Drug exposure can resemble idiopathic lichen planus
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| ===Affected areas===
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| *Skin (cutaneous lichen planus)
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| *Oral cavity (oral lichen planus)
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| *Genitalia (penile or vulvar lichen planus)
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| *Scalp (lichen planopilaris)
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| *Nails
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| *Esophagus
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| ==Clinical Features==
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| ===Cutaneous Lichen Planus===
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| ''Predominantly on ankles and volar surface of wrists''
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| *Four “P’s”
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| **Pruritic
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| **Purple
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| **Polygonal
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| **Papules or plaques
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| *Wickham’s striae: Fine white lines visible on surface of papules or plaques
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| *Koebner reaction: Lesions develop in areas of trauma (e.g., scratching)
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| ===Cutaneous variants===
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| ====Hypertrophic lichen planus====
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| *Intensely pruritic, flat-topped plaques
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| *Common sites are extensor surfaces of lower extremities
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| ====Atrophic lichen planus====
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| *Violaceous, round or oval, atrophic plaques
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| *Common sites are legs
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| *Often resolution of annular or hypertrophic lesions
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| ====Annular lichen planus====
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| *Violaceous plaques with central clearing
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| *Common sites are penis, scrotum, and intertriginous areas
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| ====Bullous lichen planus====
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| *Vesicles or bullae within existing lesions
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| *Common sites are legs
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| ====Actinic lichen planus (lichen planus tropicus)====
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| *Photodistributed eruption of hyperpigmented macules, annular papules, or plaques
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| *Most common in Africa, Middle East, and India
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| ====Lichen planus pigmentosus====
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| *Gray-brown or dark brown macules or patches
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| *Sun-exposed or flexural areas
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| *Pruritis minimal or absent
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| ====Inverse lichen planus====
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| *Erythematous to violaceous papules and plaques
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| *Intertriginous sites (e.g., axillae, inguinal creases, inframammary area, limb flexures)
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| *Hyperpigmentation is common
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| *Scales and erosions may be present
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| ====Overlap syndromes====
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| *Lichen planus pemphigoides
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| *Lichen planus-lupus erythematosus overlap syndrome
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| ====Other forms of lichen planus====
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| *Nail lichen planus [[File:Lehman, 2009 Fig11.tiff|thumb|Lichen planus involving the nails]]
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| **Varies from minor atrophy to total nail loss
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| *Lichen planopilaris (follicular lichen planus)
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| **Keratotic papules that may coalesce into plaques
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| **Classic site is the scalp
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| **May be in other body sites (e.g., Graham-Little-Piccardi-Lasseur syndrome)
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| **Untreated, can result in scarring and permanent alopecia
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| *Oral lichen planus [[File:Lichen Planus Fig7.tiff|thumb|Lichen planus on the lips and the lateral border of the tongue]]
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| **Painful, frequent loss of appetite
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| **May lead to secondary candida infection
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| *Genital lichen planus
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| **Involves glans of penis or epithelium of vulva, vestibule, vagina, and mouth
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| **Often resistant to treatment
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| *Esophageal lichen planus
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| **Associated dysphagia or odynophagia
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| **Concomitant oral, genital, or cutaneous lichen planus
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| *Otic lichen planus
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| **Erythema, induration, and stenosis of external auditory canal
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| **Thickening of TM
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| **Otorrhea
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| **Hearing loss
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| ==Differential diagnosis==
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| The differential diagnosis for lichen planus includes:
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| *Chronic graft-versus-host disease
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| *Psoriasis
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| *Atopic dermatitis
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| *Lichen simplex chronicus
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| *Subacute cutaneous lupus erythematosus
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| *Discoid lupus erythematosus
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| *Pityriasis rosea
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| *Secondary syphilis
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| *Prurigo nodularis
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| *Paraneoplastic pemphigus/paraneoplastic autoimmune multiorgan syndrome (PAMS)
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| *Oral leukoplakia
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| *Oral candidiasis
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| *Pemphigus vulgaris
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| *Benign mucous membrane pemphigoid
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| *Lichenoid drug eruption
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| **Antimicrobial substances
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| ***Aminosalicylate sodium, ethambutol, griseofulvin, ketoconazole, streptomycin, tetracycline, trovafloxacin, isoniazid
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| **Antihistamines
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| ***Ranitidine, roxatidine
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| **Antihypertensives/antiarrhythmics
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| ***ACE-inhibitors (captopril, enalapril), doxazosin, beta blockers (propranolol, labetalol, sotalol), methyldopa, prazosin, nifedipine, quinidine
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| **Antimalarial drugs
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| ***Chloroquine, hydroxychloroquine, quinine
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| **Antidepressives/antianxiety drugs/antipsychotics/anticonvulsants
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| ***Amitriptyline, carbamazepine, chlorpromazine, levomepromazine, methopromazine, imipramine, lorazepam, phenytoin
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| **Diuretics
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| ***Thiazide diuretics (chlorothiazide and hydrochlorothiazide), furosemide, spironolactone
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| **Antidiabetics
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| ***Sulfonylureas (chlorpropamide, glimepiride, tolazamide, tolbutamide, glyburide)
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| **Metals
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| ***Gold salts, arsenic, bismuth, mercury, palladium, lithium
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| **Non-steroidal-antiinflammatory drugs (NSAIDs)
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| ***Acetylsalicylic acid, benoxaprofen, diflunisal, fenclofenac, flurbiprofen, ibuprofen, indomethacin, naproxen, sulindac
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| **Proton pump inhibitors
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| ***Omeprazole, lansoprazole, pantoprazole
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| **Lipid lowering drugs
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| ***Pravastatin, simvastatin, gemfibrozil
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| **TNF-alpha antagonists
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| ***Infliximab, adalimumab, etanercept, lenercept
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| **Varia
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| ***Allopurinol, bleomycin, cinnarizine, cyanamide, dapsone, hydroxyurea, hepatitis B-vaccine, imatinib, immunoglobulins, interferon alfa, l-thyroxin, levamisole, mesalamine, methycran, penicillamine, procainamide, pyrimethamine, pyrithioxine, quinacrine, sildenafil, sulfasalazine, terbinafine, trihexyphenidyl, ursodeoxycholic acid
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| ==Diagnosis==
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| Often clinical diagnosis
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| ===Questions to ask===
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| *Current medications
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| *Pruritus
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| *Oral or genital erosions or pain
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| *Dysphagia or odynophagia
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| *Risk factors for HCV
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| ===Physical exam===
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| *Expose and examine all cutaneous surfaces
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| ===Workup===
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| ====Biopsy====
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| *Punch biopsy or shave biopsy
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| *Immunofluorescence studies if bullous lesions present
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| ====Histologic Findings====
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| *Pathologic findings seen in lichen planus
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| **Hyperkeratosis with
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| **Vacuolization of basal layer with increased melanin
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| **Hypergranulosis with irregular widening/elongation of rete ridges
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| **Apoptotic keratinocytes in lower epidermis (Civatte bodies) and papillary dermis (eosinophilic colloid bodies)
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| **Formation of small clefts with lymphocytic infiltrate at dermal-epidermal junction
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| ====Dermoscopy====
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| *Wickham’s striae
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| ====HCV testing====
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| *Routine testing controversial
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| ==Managment==
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| ====Cutaneous====
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| Self-limiting disease, usually resolves within 8-12 months
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| *First-line
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| **[[Topical corticosteroid]]
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| ***High potency (e.g., trunk, extremities)
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| ****0.05% betamethasone dipropionate cream/ointment BID
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| ****0.05% diflorasone diacetate cream/ointment BID
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| ***Mid- or low-potency (e.g., intertriginous areas, facial skin)
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| **Intralesional corticosteroids (hypertrophic lichen planus)
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| ***2.5 to 10 mg/ml triamcinolone acetonide q4-6 weeks
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| *Second-line therapy
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| **For generalized disease or local corticosteroid-refractory disease
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| ***Oral [[glucocorticoids]]
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| ****Optimal dose/duration unknown
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| ****30 to 60 mg qd 4-6 weeks followed by 4-6 week taper
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| ***Phototherapy (e.g, Uultraviolet B, psoralen plus Ultraviolet A)
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| ***Oral acitretin
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| ====Genital====
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| *Topical corticosteroids or topical calcineurin inhibitors
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| ====Lichen planopilaris====
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| *Topical corticosteroids or intralesional corticosteroids
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| ====Oral====
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| *Topical corticosteroids
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| ====Nail====
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| *Systemic or intralesional corticosteroids
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| ==Disposition==
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| *Outpatient treatment
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| ==Prognosis==
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| ====Cutaneous lichen planus====
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| *Remits within 1 to 2 years
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| ====Oral, genital, scalp, and nail lichen planus====
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| *More persistent and resistant to therapy
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| *Squamous cell carcinoma risk is unclear (highest risk with erythematous or erosive oral and genital lichen planus)
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| Monitor for medication adverse effects
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| ==External Links==
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| ==References==
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| *Goldstein, BG, Goldstein, AO, Mostow, E. Lichen planus. In: UpToDate, Dellavalle, RP, Callen, J (Ed), UpToDate, Waltham, MA, 2017.
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