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Lichen planus

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Lichen planus



Introduction 

Lichen planus is a non-infectious, itchy rash that can affect many areas of the body.

Affected areas can include the:



arms, legs and trunk 



mouth (oral lichen planus)



nails and scalp



vulva, vagina and penis



The exact cause of lichen planus is unknown. However, the condition isn't infectious and doesn't usually run in families. It can't be passed on to other people, including sexual partners.

A GP can usually diagnose lichen planus by examining the rash and asking about your symptoms. Oral lichen planus is often diagnosed by a dentist during routine dental check-ups.

Who's affected by lichen planus

Lichen planus is thought to affect 1-2% of the worldwide population. It's more common in adults over the age of 40.

Lichen planus of the skin affects men and women equally. However, oral lichen planus is more common in women. The mouth is affected in around 50% of all cases of lichen planus (oral lichen planus).

Treating lichen planus

There's no single treatment that can cure lichen planus completely. However, treatments are available to help manage the symptoms and make living with it easier. For example, steroid creams or ointments are often used to help relieve the itch and control the rash.

Most cases of lichen planus of the skin clear up on their own within six to nine months. The rash rarely lasts longer than 18 months. However, oral lichen planus and lichen planus that affects the genital area may be more persistent.

Erosive lichen planus

Erosive lichen planus is a rare form of lichen planus that can last a long time. It causes painful ulcers to develop in the mouth and in the genital areas of both males and females.

In some cases, long-term erosive lichen planus can increase the chance of some types of cancer developing.

 

 


 


Lichen planus of the skin usually occurs in adults over the age of 40 

 

Pharmacy and medicines

 


Using your local pharmacy's services could save you an unnecessary trip to your GP

 

 

 

Symptoms of lichen planus 

The symptoms of lichen planus vary, depending on which area of the body is affected.

Areas of the body most commonly affected by the condition include the:



skin



mouth



penis



vulva (external female sex organs) and vagina



Lichen planus of the skin

The symptoms of lichen planus of the skin are:



purple-red coloured bumps (papules) that are slightly raised, shiny and have a flat top. The papules usually measure 3-5mm in diameter and may also have irregular white streaks (Wickham's striae)



thicker scaly patches can appear, usually around the ankles – this is known as hypertrophic lichen planus



itchy skin



Lichen planus of the skin often affects the wrists, ankles and lower back, although other parts of the body can also be affected.

Thickened (hypertrophic) lichen planus affects the shins, and ring-shaped lichen planus affects creases in the skin, such as the armpits.

After the papules have cleared, the affected area of skin can sometimes become discoloured.

Lichen planus of the mouth (oral lichen planus)

The symptoms of oral lichen planus are:



a white pattern on the tongue and inner cheeks



red and white patches in the mouth



burning and discomfort in the mouth while eating or drinking



painful red gums



Mild cases of oral lichen planus don't usually cause any pain or discomfort.

Lichen planus of the penis

The symptoms of lichen planus of the penis are:



purple or white ring-shaped patches on the tip of the penis (glans)



bumps (papules) that are flat-topped and shiny



a non-itchy rash



Lichen planus of the vulva and vagina

The symptoms of lichen planus of the vulva and vagina include:



soreness, burning and rawness around the vulva



the vulva may be covered in white streaks and be a red, pink or pale white colour



if the vagina is affected, sexual intercourse can be painful



if the outer layers of skin break down, moist, red patches can form



scar tissue can form, which distorts the shape of the vagina



a sticky yellow or green discharge, which may be bloodstained



the opening of the vagina can become narrowed



Other areas

Lichen planus can sometimes affect other areas, including:



the nails – which can become thinner, ridged and grooved, or they may become darker, thicker or raised; they may sometimes shed or stop growing



the scalp – red patches can appear around clusters of hair; in some cases, permanent hair loss can occur



Causes of lichen planus 

The cause of lichen planus is unknown.

It's thought to be related to the immune system, or an abnormal response of the immune system to certain medicines.

Lichen planus isn't infectious, doesn't usually run in families and can't be passed on to others.

Autoimmune reaction

The immune system protects your body against illness and infection by producing antibodies (proteins) that attack bacteria and viruses.

In people with lichen planus, it's thought that the immune system becomes overactive, causing an excess amount of proteins to be produced, which inflame the skin. This is known as an autoimmune reaction and causes the symptoms of lichen planus.

Reaction to medication

A reaction to certain medications is another possible cause of lichen planus. For example:



gold injections – these are disease-modifying anti-rheumatic drugs (DMARDs) that are sometimes injected into the muscles of people with arthritis to help reduce inflammation and painful joints



antimalarial tablets – these help treat and prevent malaria (a serious tropical disease spread by mosquitoes)



Diagnosing lichen planus 

Lichen planus is often diagnosed by a GP or dentist examining the affected area. 

Lichen planus of the skin

Your GP may be able to make a diagnosis based on the characteristic rash. However, lichen planus can be mistaken for other skin conditions, such as eczema, which also causes the skin to become red, flaky and itchy.

If your doctor is unable to make a confident diagnosis by examining your skin, they may want to take a small skin sample (biopsy), which will be examined under a microscope.

If a skin biopsy is required, you'll be given a local anaesthetic to numb the affected area so you don't feel any pain or discomfort during the procedure.

Lichen planus of the mouth (oral lichen planus)

A dentist or doctor can diagnose oral lichen planus by looking at the inside of your mouth.

A biopsy may be recommended to confirm the diagnosis. A sample of mouth tissue will be removed so that it can be examined under a microscope. As with lichen planus of the skin, you'll be given a local anaesthetic to numb the pain.

Treating lichen planus 

There's no cure for lichen planus, so treatments aim to ease the symptoms and clear the rash. Mild lichen planus doesn't require treatment.

Self-help

Below is some general self-help advice that can help ease your symptoms and prevent them getting worse.

Lichen planus of the skin



avoid washing with soap or bubble bath – use plain warm water instead



wash your hair over a basin to stop affected areas of skin coming into contact with shampoo



use an emollient to moisturise your skin 



Lichen planus of the mouth (oral lichen planus)



avoid eating spicy foods and anything acidic, such as fruit juice, because they can irritate oral lichen planus



avoid eating sharp food, such as crusty bread



avoid drinking alcohol, particularly spirits



if areas of your mouth are painful, stick to soft, bland foods, such as mashed potatoes and porridge



if possible, continue to use your usual toothpaste



avoid using mouthwashes that contain alcohol because they may be too strong, and keep your mouth as clean as possible



visit your dentist regularly to help keep your teeth and gums healthy



Lichen planus of the genitals



avoid washing with soap or bubble bath – use plain warm water or a soap substitute instead, such as aqueous cream



use an emollient, such as petroleum jelly, before and after urinating



applying ice packs to the affected areas may soothe itching and swelling (never apply an ice pack directly to your skin – wrap it in a clean tea towel before placing it on your body)



women should avoid wearing tights



Lichen planus of the skin, hair and nails

There are a number of medications and treatments that may be recommended for lichen planus of the skin, hair and nails. These are outlined below.  

Corticosteroid creams and ointments

Corticosteroid creams and ointments contain corticosteroids (artificial hormones) and are used to treat inflammatory skin conditions. They are often referred to as topical corticosteroids.

Topical corticosteroids help treat the swelling (inflammation) and redness caused by lichen planus. Strong topical corticosteroids, such as clobetasol propionate, are also effective in reducing any itchiness you may have.

Treatment is applied to the red or purple itchy spots, but should be stopped when the colour of the rash changes to brown or grey. This pigment change occurs when the inflammation has settled. Continuing to apply the corticosteroid cream to the brown areas of skin will gradually cause the skin to thin.

The side effects of corticosteroids can vary, depending on the:



type and severity of treatment being used



how long the treatment is used for



nature of the condition being treated



Potential side effects of topical corticosteroids can include:



redness or burning and stinging of the skin



skin rash



thinning of the skin (atrophy)



stretch marks (striae)



contact dermatitis – a condition that causes skin inflammation



excessive hair growth (hypertrichosis)



lightening of the skin



Always check the patient information leaflet that comes with your medicine.

Corticosteroid tablets

Corticosteroid tablets are sometimes used to treat severe cases of lichen planus, when the symptoms aren't being effectively controlled with creams or ointments.

Possible side effects of corticosteroid tablets used on a short-term basis can include:



increased appetite



weight gain



insomnia



fluid retention (inability to pass urine)



mood changes, such as feeling irritable or anxious



Other treatments

Other treatments recommended for lichen planus of the skin are outlined below. 



Antihistamines – these are often used to treat symptoms ofallergies, such as itchy skin. If you have lichen planus of the skin that's causing itchiness, antihistamines may be prescribed to help reduce this.



Light treatment – there are two types of light treatment: ultraviolet B (UVB) and psoralen plus ultraviolet A (PUVA). UVB is the most commonly used light treatment, but PUVA may be recommended in severe or widespread cases of lichen planus that don't respond to other types of treatment. 



Acitretin – this medication is only prescribed by a specialist and is used to treat severe cases of lichen planus. The tablets have some associated side effects and may not mix well with other medicines. Your specialist can offer advice.



Lichen planus of the mouth (oral lichen planus)

Mild cases of oral lichen planus won't need any treatment. In more severe cases, treatment includes:



a mouthwash that contains an anaesthetic to temporarily numb the mouth, which makes eating easier



corticosteroid sprays, mouthwashes, pastes and dissolvable lozenges



a mouthwash or gel that contains an antiseptic to help prevent the build-up of plaque in your mouth



In more severe cases of oral lichen planus, corticosteroid tablets (see above) may also be used on a short-term basis.

It can be difficult to prevent oral lichen planus, but to keep the lining of your mouth healthy it's recommended that you:



stop smoking (if you smoke)



avoid drinking large amounts of alcohol



have a healthy, balanced diet, including plenty of fresh fruit and vegetables



You should also maintain good oral hygiene by cleaning your teeth at least twice a day, and having regular dental check-ups, so that any problems with your teeth or mouth can be identified and treated early.

Other treatments

If corticosteroids are not effective in treating your symptoms, you may be prescribed a medication that suppresses your immune system to try to limit the autoimmune reaction that's thought to cause lichen planus.

These types of treatments are known as immunomodulating agents. Depending on which area of your body is affected by lichen planus, treatments that may be recommended for you can include: treatments such as tacrolimus 



topical immunomodulating agents (used to treat lichen planus of the skin) – treatments such as tacrolimus ointment and pimecrolimus cream are rubbed directly onto the skin



immunomodulating agents (used to treat lichen planus of the mouth) – these are usually available in the form of tablets or capsules, and can be used to treat severe cases of oral lichen planus



These treatments can cause a number of different side effects, which your specialist can discuss with you.

You'll also need to have regular blood tests while taking immunomodulating agents, particularly in the early stages of treatment.

Complications of lichen planus 

Complications of lichen planus may include discoloured skin and, in some cases, erosive lichen planus may develop into certain types of cancer.

Skin pigmentation

After the lichen planus rash has cleared up, the affected area of skin may be a different colour to what it was originally. There may be a brown or grey mark, which can sometimes last for months. This is known as post-inflammatory hyperpigmentation, and tends to be more noticeable in people with darker skin.

Erosive lichen planus

Erosive lichen planus is a long-lasting (chronic) form of lichen planus that causes painful ulcers to develop, as well as burning and discomfort in the genital areas of both male and females.

Occasionally, in around 2% of cases, long-term cases of erosive lichen planus can develop into certain types of cancer, such as:



mouth cancer  



vulval cancer



penile cancer



Regularly examining yourself and being aware of any changes that occur will help you to identify any problems at an early stage. Pay close attention to ulcerated areas in your mouth or genitals that don't heal and persist for a long time. Visit your GP immediately if you notice any changes that you're concerned about.

You should also visit your dentist regularly to ensure that your teeth and gums remain healthy, and that any ulcers or patches that form in your mouth are examined and treated promptly. Depending on individual circumstances, dental check-ups for adults are recommended anywhere between every 3 to 24 months.
 


Lichen planus