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Lichen planus

Lichen planus is an inflammatory disease that usually affects the skin, the mouth, or sometimes both. more...

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The cause of lichen planus is not known, however there are cases of lichen planus-type rashes (known as lichenoid reactions) occurring as allergic reactions to medications for high blood pressure, heart disease and arthritis. These lichenoid reactions are referred to as lichenoid mucositis (of the mucosa) or dermatitis (of the skin). Lichen planus has been reported as a complication of chronic hepatitis C virus infection. It has been suggested that true lichen planus may respond to stress, where lesions may present on the mucosa or skin during times of stress in those with the disease. Lichen planus affects women more than men 3:2, and occurs most often in middle-aged adults. Lichen planus in children is rare.

Clinical features

The typical rash of lichen planus takes the form of well-defined, purplish, polygonal, extremely itchy bumps on the skin. The commonly affected sites are near the wrist and the ankle. The rash tends to heal with prominent blue-black or brownish discoloration that persists for a long time. Besides the typical lesions, many morphological varieties of the rash may occur.

The presence of lesions is not constant and may wax and wane over time.

Inside the mouth, the disease may present in the (1) reticular form or in the (2) erosive form. (1) The reticular form is the more common presentation and manifests as white lacy streaks on the mucosa (known as Wickham's striae) or as smaller papules (small raised area). The lesions tend to be bilateral and are asymptomatic. The lacy streaks may also be seen on other parts of the mouth, including the gingiva (gums), the tongue, palate and lips. (2) The erosive form presents with erythematous (red) areas that are ulcerated and uncomfortable. The erosion of the thin covering of cells (the epithelium) may occur in multiple areas of the mouth, or in one area, such as the gums. Wickham's striae may also be seen near these ulcerated areas.

Lichen planus may also affect the genital mucosa. It can resemble other skin conditions such as atopic dermatitis and psoriasis.

Differential Diagnosis

The clinical presentation of lichen planus may also resemble other conditions, including:

  • Lichenoid drug reaction
  • Lupus Erythematosus
  • Chronic Ulcerative Stomatitis
  • Pemphigus Vulgaris
  • Benign Mucous Membrane Pemphigoid

A biopsy is useful in identifying histological features that help differentiate lichen planus from these conditions.


Currently there is no cure for lichen planus but there are certain types of medicines used to reduce the effects of the inflammation. Lichen planus may go into a dormant state after treatment. There are also reports that lichen planus can flare up years after it is considered cured.


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Koebner Streak - lichen planus
From American Family Physician, 2/1/02 by Sylvia Hsu

A 45-year-old woman presented with a pruritic eruption of one month duration. Her medications included triamcinolone inhaler, albuterol inhaler, and beclomethasone nasal spray for asthma; carbamazepine and clonazepam for seizures; cyclobenzaprine and tramadol for back pain; estrogen replacement; furosemide; and potassium replacement.

On physical examination, there were multiple flat-topped papules with white scale on her hands, wrists, and shins. She also had lacy, white reticulations on her buccal mucosa.


Based on the patient's history and physical examination, which one of the following is the correct diagnosis?


The answer is D: lichen planus, which was established by skin biopsy. It was not consistent with a drug-induced lichen planus, because there were no eosinophils and no parakeratosis.

An inflammatory dermatosis of unknown etiology, lichen planus classically presents as shiny, violaceous, flat-topped, polygonal papules, 2 mm to 10 mm in diameter. Fine, lacy, white scale (Wickham's striae) adhere to well-developed papules, resembling a reticulate network of lichen. These are easier to appreciate if a drop of microscope lens oil is placed on the papule and a glass slide is pressed gently over the lesion.

Contact dermatitis due to poison ivy can also present as a linear distribution of pruritic lesions. However, instead of flat-topped papules as seen in lichen planus, the lesions of contact dermatitis are often vesicular.

Discoid lupus erythematosus typically presents as atrophic or scarring plaques on the head and neck. They are usually not pruritic.

Guttate psoriasis is characterized by erythematous plaques with thick white scale, unlike lichen planus, which has a fine, lacy scale.

Verruca plana, or flat warts, are flat-topped like the lesions of lichen planus, but are smooth instead of scaly, and are usually skin-colored, pink, or light brown instead of violaceous.

Affecting less than 1 percent of the population worldwide, lichen planus occurs in both sexes, most often between 30 and 60 years of age. The initial lesions are usually located on the flexural surfaces of the wrists, arms, and legs, but the trunk, thighs, and genitalia also may be involved. Evolving over several weeks, lesions may be grouped, annular, or generalized in arrangement. Trauma during the early stages of evolution may induce the isomorphic (Koebner) phenomenon to produce a linear distribution of papules. While some patients remain asymptomatic, the eruption is often pruritic with severity related to the degree of involvement.1

Involvement of the oral mucosa occurs in 60 percent of patients and may be the only manifestation of the disease. The most common pattern of oral disease reveals a reticular network of white hyperkeratosis on the buccal mucosa. Involvement of the lips, gums, and tongue is not uncommon. While most cases of mucosal lichen planus are nonerosive and asymptomatic, ulcerative and atrophic variants may cause painful erosions and marked distress.

The appearance of the typical lichen planus papule, characterized by the four Ps (purple, pruritic, polygonal, papule), often allows a clinical diagnosis of the lesion.(1) Histopathologic examination of a biopsy specimen can confirm the diagnosis in atypical cases. Other papulosquamous disorders should be considered in the differential diagnosis, including guttate psoriasis, pityriasis rosea, and discoid lupus erythematosus. Annular lesions may mimic those of granuloma annulare or sarcoid; however, the lesions of these granulomatous disorders lack the fine scale of lichen planus papules. The white buccal lesions of oral lichen planus may necessitate biopsy to exclude leukoplakia, candidiasis, and secondary syphilis.(2)

Lichen planus-like eruptions may occur following exposure to industrial compounds such as color film developer or with use of many commonly prescribed medications, including diuretics, antihypertensives, and hypoglycemic agents. Exposure and medication history should be reviewed as these lesions resolve after discontinuation of the offending agent.(1)

Most localized cutaneous eruptions of lichen planus resolve within 12 to 18 months, leaving residual hyperpigmentation that fades with time. Patients with generalized eruptions or mucosal lesions have a more prolonged course. Topical or intralesional steroids suppress inflammation and cause regression of lesions in mild cases, while more severe cases may require systemic corticosteroids, retinoids, or cyclosporine.(3) Antihistamines can be useful for pruritus with recurrence in less than 20 percent of patients.(2)


(1.) Daoud MS, Pittelkow MR. Lichen planus. In: Freedberg IM, Eisen AZ, Austen KF, Goldsmith LA, Katz SI, Fitzpatrick TB, eds. Fitzpatrick's Dermatology in general medicine. 5th ed. New York: McGraw-Hill, 1999:561-75.

(2.) Lookingbill DP, Marks JG. Inflammatory papules. In: Principles of dermatology. 2d ed. Philadelphia: WB Saunders, 1993:184-5.

(3.) Black MM. Lichen planus and lichenoid disorders. In: Rook A, Wilkinson DS, Ebling FJ, Champion RH, eds. Textbook of dermatology. 6th ed. Malden, Mass.: Blackwell Science, 1998:1899-917. n

The editors of AFP welcome submission of photographs and material for the Photo Quiz department. Contributing editor is Marc S. Berger, M.D., C.M. Send photograph and discussion to Marc S. Berger, M.D., C.M., P.O. Box 219, Crystal Beach, FL 34681-0219.

COPYRIGHT 2002 American Academy of Family Physicians
COPYRIGHT 2002 Gale Group

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