Lichen planus (LP) is a self-limiting condition in most cases, but it can occasionally persist for an indefinite period. Though symptoms may resolve within one or two years, recurrences are common, with or without treatment.
Treatment of lichen planus
The chief aims in the treatment of lichen planus are:
- Finding and avoiding exposure to offending or exacerbating agents, such as drugs, or dental devices, sharp-edged teeth or dental procedures. Drugs which are likely to produce lichenoid reactions include
- Cardiovascular drugs
- Drugs used in arthritis
- Drugs used to treat malaria
- Non-steroidal anti-inflammatory drugs (NSAIDs)
- Relieving the pain of the erosions
- Helping the patient keep the affected part clean, which has a powerful effect upon the resolution of the lesions
- Prevention or early detection of malignant transformation of the lesions
Pharmacological modes of treatment
The primary choice of treatment for lichen planus are potent corticosteroids. Topical use is preferred as the first line of treatment, followed by oral administration in cases with extensive and severe lesions and symptoms.
Topical corticosteroids
Topical corticosteroids in the form of ointments or creams are the most commonly used drugs in the control of OLP. They reduce the inflammation, and thus relieve erythema and itching. These include:
- Fluocinolone acetonide, which produces little if any adrenal suppression after six months of topical treatment
- Triamcinolone acetonide
- Betamethasone valerate
- High-potency corticosteroids such as clobetasol propionate
Side effects include:
- Local effects
- erythema
- stinging sensation of the skin
- contact dermatitis
- cutaneous atrophy with prolonged application
- cutaneous striae
- hypopigmentation of affected areas
- Adrenal suppression
- Secondary oral candidiasis
Application should be terminated when the rash changes from red or purplish to brown or gray, to avoid overtreatment after the inflammation has ceased.
Other topical agents
Other topical agents used in refractory cases include:
- Immunosuppressants
- Retinoids
- Immunomodulators such as the calcineurine inhibitors Tacrolimus and pimecrolimus are used for intractable OLP. Disadvantages include:
- early recurrence
- local irritation
- hyperpigmentation of the mucous membrane
- potential to develop squamous cell carcinoma (SCC) by interfering with cell signaling pathways
The benefits of local drug application include:
- Less systemic absorption and therefore reduced adverse effects
- Cost-effectiveness as drug delivery is more efficient, with lesser amounts of the drug being taken up by the body
- The use of custom trays enables the precise control of exposure in terms of dosage and time, of the lesion to the drug used
Systemic drugs in LP
Systemic drugs used in LP include:
- Corticosteroids such as prednisolone to control inflammatory activity. Side-effects include powerful adrenal suppression even with a short course of oral corticosteroids. Adverse effects during treatment include:
- Fluid retention
- Weight gain
- Sleep disturbances
- Griseofulvin for control of fungal infections
- Metronidazole for antibacterial action
- Thalidomide
- Hydroxychloroquine
- Retinoids – isotretinoin, tretinoin and other retinoids are useful in reducing the symptoms of LP, but their adverse effects include:
- Cheilitis
- Teratogenicity
- Hypertriglyceridemia
- Hepatotoxicity
The retinoid acitretin is a costly and toxic drug which is reserved for recalcitrant cases of LP. Since it is highly teratogenic, it is not used in women who may conceive during the treatment, especially because it remains in the body for three months after the cessation of therapy.
- Mycophenolate mofetil, which requires to be taken long-term but is quite effective, if expensive, is an immunosuppressive drug
- Dapsone for its anti-inflammatory action
- Monoclonal antibodies such as efalizumab used as immunosuppressants
- Low-dose low-molecular weight heparin by subcutaneous injection to inhibit T-cell migration
Non-pharmacological treatment of LP
Non-drug-based treatment of LP includes:
- Photochemotherapy with psoralen and ultraviolet-A band (PUVA) therapy has shown effectiveness in resolving symptoms of cutaneous and oral LP. It has disadvantages such as:
- Headache
- Nausea
- Dizziness
- Paresthesia or altered sensation
- Photosensitivity for 24 hours following treatment
- Potential for development of SCC
- Ultraviolet B therapy is used in less severe cases
- Photodynamic therapy using methylene blue: this had some benefit in reducing symptoms and signs of LP
- Surgical methods are used mainly to treat areas which show severe dysplasia, and thus prevent or detect any progression to carcinomas. They may include:
- Surgical excision
- Cryotherapy
- Laser excision, either with carbon dioxide or Nd:YAG laser is sometimes considered a first-line treatment in painful erosive or atrophic OLP because of its effectiveness in resolving symptoms
Treatment of cutaneous LP
Cutaneous LP is treated as follows in line with current thinking:
- Topical high-potency steroids such as clobetasol as first-line therapy
- Oral corticosteroids as second-line therapy in recalcitrant cases
- Phototherapy or photodynamic therapy for severe disease
Treatment of genital LP
Treatment of genital LP may include:
- Topical corticosteroid ointments, especially triamcinolone acetonide or clobetasol propionate
- Topical tacrolimus ointment seems to be as effective as clobetasol in vulvovaginal LP
- Topical aloe vera gel
Treatment of oral LP
Oral LP is currently treated with:
- Topical high-potency steroids such as clobetasol initially
- Topical corticosteroids
- Topical calcineurine inhibitors such as tacrolimus if the condition does not respond to the corticosteroids
- Topical aloe vera gel
- Carbon dioxide laser vaporization of erosive oral LP
- Oral corticosteroids in refractory or widespread disease
Symptomatic treatment
Symptomatic treatment in oral LP includes:
- Anesthetic mouthwashes to relieve the pain of erosive lesions
- Antiseptic (but not alcohol-containing) mouthwashes to help maintain good oral hygiene
Symptomatic treatment in cutaneous LP includes the use of antipruritic agents such as antihistamine creams topically. Genital LP may require the use of:
- Topical lidocaine ointment to relieve the pain of erosions
- Water-based lubricant jelly to relieve dyspareunia
Follow-up
Follow up is vital to improve the detection rate of SCC. Patients should be reviewed at least once in four months, and those presenting with dysplasia at the initial visit require more intensive follow-up.
Counseling and psychotherapy are required and helpful for those patients who have severe and painful LP which interferes with their daily activities.
Caring for lichen planus at home
The following measures have been recommended for patients with cutaneous lichen planus:
- Avoid contact with soap or shampoo on the skin and bathe with warm water instead
- For the genital areas, avoid contact with urine and use ice packs (wrapped in towels) to relieve itching
In oral lichen planus, symptomatic resolution is aided by:
- Keeping the mouth clean but avoiding alcohol-containing mouthwashes which can irritate the lesions
- Avoiding crusty, hard, spicy or hot foods
- Avoiding alcohol and smoking
Further Reading