Lichen planus

What is lichen planus?

Lichen Planus is a disorder that can affect any part of the skin and/or mucosal surfaces of the body. It is not infectious nor contagious. It usually persists over time (it is a chronic disorder) before usually stabilising and resolving. It is a condition in which the immune system is set off inappropriately and causes damage and inflammation. It is not a harmful or dangerous condition in that it does not lead to serious harm to the body. Your General Practitioner (GP) can diagnose, start treatments, and support you, or refer you for diagnosis and treatment where needed.

What does lichen planus look and feel like?

Since lichen planus can affect any part of the skin or mucosal surface, its appearance depends on the area involved. Classically, lichen planus is an itchy eruption, consisting of slightly raised, purplish/mauve flat-topped spots on areas such as the wrists, legs, and tops of the feet. In skin of colour the spots may be dark brown or black. The spots may have lacy white streaks over them, when fresh. The spots may join to form larger patches. The rash may spread over the body.

In other forms, lichen planus can affect the scalp, causing either patchy hair loss (lichen planopilaris) or affecting the front hairline, causing it to seemingly move backwards (frontal fibrosing alopecia). Hair destruction can be permanent. Lichen planus can involve the nails, causing altered appearances such as excess dryness and ridging of the nails, discolouration of the nails, lifting off of the nail edges, thickened skin under the nails, and finally, permanent nail destruction and nail loss. Lichen planus can affect the penis, sometimes leading to foreskin damage that may lead to permanent scarring and inability to retract the foreskin or causes erections to be painful, and can affect the vulva and vagina, again, causing itch or soreness, and scarring. Some people suffer with oral lichen planus, where the gums and inner surfaces of the mouth are affected, and rarely, can develop it in the oesophagus, causing swallowing difficulties. It is rare, but not impossible, to develop anal lichen planus.

Rare forms of lichen planus include lichen planus pigmentosa, which causes dark patches to develop on the face, neck, armpits, elbows, groins, and knees. Rarely, lichen planus can appear as blisters.

A person may have only the skin, or one site involved, or have many areas affected.

What causes lichen planus?

An exact cause for the development of lichen planus has not been found. Possible triggers may include the following:

• Certain viruses, such as hepatitis C, hepatitis B, herpes simplex virus (cold sore virus), human herpesvirus, and varicella zoster virus (chickenpox), have been implicated as possible triggering agents, but there is no conclusive evidence of this
• The influenza (‘flu') and hepatitis B vaccinations have rarely been reported as possible triggers. This is an uncommon association
• Certain metals, used for fillings, such as mercury (amalgam), copper, and gold, may lead to allergic reactions in the mouth that may trigger oral lichen planus. Oral lichen planus has also been linked with chewing of betel nut leaves, which is common in South-east Asia
• Medicines, such as common tablets for high blood pressure, antibiotics, malaria, anti-inflammatories for example for pain, etc. may trigger a ‘lichenoid’ or lichen planus-like rash, which is sometimes very difficult to discern between typical lichen planus
• There is mixed evidence that ultraviolet filters in sunscreens and hair care products may be associated with the development of frontal fibrosing alopecia and lichen planopilaris; similarly, contact with certain irritants may lead to a lichen-planus like contact reaction
• Finally, stress, depression, and anxiety have been thought to be triggers to develop, or at the least, lead to flares, in lichen planus

Things you can do to help yourself

It is important to keep your skin moisturised; moisturising helps restore the skin barrier, which may be damaged by the inflammation. Moisturising will also reduce itch. Cooling creams (moisturisers with menthol) may also reduce itch; these can be applied as often as are needed. Do remember that moisturisers are flammable; keep yourself, and anything they may come in to contact with, from naked flames.

• Good skin care is also necessary for those affected by genital lichen planus; using moisturiser as soap, or using soap-free and fragrance-free cleaning products, will help reduce damage and ease symptoms
• For people with oral lichen planus, it is important to maintain regular review with a dentist
• It is important that people with frontal fibrosing alopecia do not stop protecting their skin, and especially their face, against excessive sun exposure and avoid burning
• When the nails are affected, keep nails trimmed; avoid harsh treatments such as manicures and pedicures, and nail cosmetics such as gel nails & acrylics as they can worsen appearances (Koebner phenomenon)
• Some uncommon forms of lichen planus (actinic lichen planus or facial lichen planus pigmentosa) may worsen or cause more symptoms if one excessively exposes themselves to sunlight. A high-factor, broad-spectrum sunscreen or sunblock (SPF30+ and 5-star rating), and other excess sun exposure prevention methods, will help prevent worsening
• Consider a pre-payment certificate to help with cost of prescriptions, if this applies to you. A pre-payment certificate is an upfront payment for prescriptions, for those who pay for these, that allows unlimited prescriptions to be obtained for a set period

Make an appointment at your GP surgery

Lichen planus is diagnosed, in most cases, by the characteristic symptoms and appearance. Make an appointment with your General Practitioner; if a diagnosis cannot be made, you may either be referred to a skin specialist, such as a GPwER/GPwSI (a GP who has also been trained in relevant areas of dermatology), or a Dermatologist. Treatments can be prescribed by your GP to start easing your symptoms.

Some of the treatments your GP may prescribe are:

• Topical steroids - are anti-inflammatory medicines to reduce the inflammation causing the rash. They are usually of potent or ultra-potent strength (i.e. strong) as Lichen planus often will not respond to weaker topical steroids; sometimes, in delicate areas such as where there are creases in the body (groin, armpits, etc.), moderately strong topical steroids are used. It is important that the precise instructions for application are followed to avoid risks and side-effects. Do not abruptly stop using topical steroids; rather, wean them off and reduce use gradually. Some patients may benefit from a regular, twice weekly, application of topical steroids to keep their skin stable and reduce the frequency, and intensity, of flares. These are usually prescribed as ointments; creams may sting though some people prefer creams for easier application

• Topical calcineurin inhibitors - are anti-inflammatory medicines that work like topical steroids. Their value is when delicate sites, such as the face, or creases of the body, need more potent treatment, or need treatment to minimise the use of topical steroids. They can also be used, twice weekly, once the rash is controlled. There are two types; the more potent tacrolimus, which is in ointment-only form, and the weaker pimecrolimus, which is in cream-only form

• Moisturisers - repair the skin, reduce itching, and improve symptoms. They can also be used as soaps to avoid using normal soaps that dry out and exacerbate skin conditions. They are helpful in lichen planus affecting the vulva and penis where skin repair is important

• Mentholated creams - are moisturisers with menthol added. Menthol has a cooling action and when applied to itchy skin, masks the itch due to the cooling sensation

• Antihistamines - generally, antihistamines do not have any role in the treatment of itch in lichen planus, but, uncommonly, some people may find that sedating anti-histamines, taken infrequently, may provide a good night’s sleep and reduce the burden of itching overnight. These medicines can cause harm; should not be used long-term; and have a risk of leading to daytime sleepiness and lack of concentration. Seek your GP's advice as to whether you are suitable for these medicines or not

• Analgesics (painkillers) - some people with severe lichen planus, for example where the mouth, vulva, and vagina, are affected, may need prescription analgesics. A topical anaesthetic, 5% lidocaine ointment, can help pain in lichen planus affecting the vulva

The PCDS website has helpful guidance for your GP to help support decision-making.

Finally, lichen planus is rarely serious or life-threatening. In certain situations, such as hypertrophic lichen planus (very thickened areas of lichen planus, more common in patients with skin of colour), rapid change, growth, pain, or bleeding from an otherwise longstanding area of lichen planus could indicate the development of a squamous cell carcinoma (skin cancer) and patients must seek urgent advice from their GP or specialist. The same advice applies to penile or vulval lichen planus; in particular, any bloody vaginal discharge or pain and/or bleeding from the skin of the penis should prompt an urgent assessment with your GP or specialist.

Your mental health

Lichen planus has been associated with depression, anxiety, irritability, and stress. It is an itchy condition, mostly, and itch is a frustrating symptom. It is not a surprise that symptoms are worse when once is rundown, tired, stressed, and their mood affected, and vice versa. Seeking help via the General Practitioner and access to psychological therapies, to improve one’s mental health, may help one to cope and manage the lichen planus.

Referral to a specialist

A specialist may be needed to diagnose lichen planus, especially the uncommon types, or lichen planus affecting the hair and nails. Some treatments, specialist treatments, are only available in hospital.

• People with oral lichen planus are usually diagnosed and managed by dentists or specialists in oral medicine
• Vaginal lichen planus will need management by a gynaecologist
• A gastroenterologist diagnoses and manages the rare form of lichen planus affecting the oesophagus

What will happen when you are referred?

Most specialist Dermatology GPs (GPwER/GPwSI) and Dermatologists can diagnose lichen planus with assessment in the clinic; in some cases, where there is doubt, or where other diagnoses need to be ruled out, sometimes a biopsy needs to be taken. This is a short operation where a small piece of skin is removed, cut out of the skin or area, after being numbed with (local) anaesthetic. This is performed awake; you will leave the department and go home after this procedure. You may have sutures in the wound.

Once diagnosed; usually treatments will be discussed and started. Treatments depend on the extent and site of the lichen planus. These can include steroid tablets or injections, therapy with ultraviolet light (phototherapy), tablet medicines such as acitretin and hydroxychloroquine, and tablets that suppress your immune-system. It is important to remember that these treatments complement treatments already prescribed by your GP.

Can lichen planus be cured?

Lichen planus cannot be cured by treatments. In most cases, lichen planus resolves itself. Available treatments aim to improve symptoms, make the disease course milder, and aim to reduce risks such as permanent hair loss (in scalp lichen planus). Lichen planus can sometimes have a waxing and waning course before eventually resolving; here, there may be periods of active disease, marked by symptoms such as itch or soreness, interspersed with periods of inactivity, where there are no symptoms. Lichen planus on the skin may resolve with ‘staining’ where rashes may look dark. These patches may take years to resolve; sometimes, they are permanent.

Other helpful resources for lichen planus

Several support groups exist for lichen planus:

• UK Lichen Planus – though the website is inactive, resources for people suffering with lichen planus remain. https://www.uklp.org.uk
• Lichen Planus support group on Facebook – membership (free) for this group is required. https://www.facebook.com/group
• Oral lichen planus support group – this is a US-based website. https://dentistry.tamu.edu/olp

Helping with other skin conditions

If you, a family member, or friend have an undiagnosed skin condition; or you want to learn more about how to treat skin conditions, please view our short video on how to get the best from this website.