Lichen Planus

What is lichen planus and who gets it?

Lichen planus is a condition that mainly affects the skin to cause an itchy rash. In some cases it affects the mouth, genitals, hair, nails, and rarely, other parts of the body. About 1 in 100 people develop lichen planus. More than two thirds of cases occur in people aged 30-60 years. However, it can occur at any age. It is not an inherited disease. It is not an infection and the rash cannot be 'caught' or passed on to others.

The cause of lichen planus is not known. A type of inflammation develops in the skin which causes the rash. However, the cause of the inflammation is not known. One theory is that the immune system may be 'triggered' by a virus or other factor in the environment to attack cells on the skin which leads to the inflammation.

A rash very similar to lichen planus occasionally develops from a known cause, but this is rare. For example:

• A rash similar to lichen planus occurs as a rare side-effect to some medicines. This is called a 'lichenoid drug eruption'. For example: antimalarials, beta-blockers, anti-inflammatory medicines, thiazide diuretics and gold injections. The rash clears within a few weeks after stopping a medicine that caused it.
• Lichen planus in the mouth is sometimes due to an allergy to mercury fillings in teeth.
• A rash similar to lichen planus occasionally develops after contact with certain chemicals used in colour photographic developing.

Lichen planus of the skin
The typical rash is small, red-purple bumps (papules). The bumps are usually shiny and flat-topped (planus means 'flat'). They vary in size from a pinhead to about 1 cm across. The number of flat topped bumps that develop varies. The rash can appear anywhere on the body but is most likely to occur on the inner wrists, lower legs and lower back. Fine white streaks often develop on the top of each bump. These are called 'Wickham's striae'.

Itch can range from mild to severe. A severe itch is common and is often the worst thing about lichen planus. The itch may disturb sleep and affect the quality of life. The itchiness is unusual in that affected people tend to rub the rash rather than scratch to ease the itch.

Sometimes the rash develops quickly over a few days. Sometimes each bump develops gradually over several weeks. Sometimes, several bumps form in a line along a previous scar. Sometimes several bumps clump together to form a large patch. New bumps may appear over time as older ones are fading away. Each bump tends to last several months before fading away.

In most cases, the rash lasts between 3-18 months and then clears. (In some cases it persists longer.) A non-itchy brown or grey mark may be left on the skin where each bump had been. These may take several months or years to fade away completely.

Lichen planus of the mouth
About half of people with a lichen planus skin rash develop white streaks on the inside of the cheeks, gums or tongue. This is usually painless and not itchy. It may not be noticed unless looked for. Sometimes lichen planus of the mouth occurs without any skin rash.

Lichen planus can also cause ulcers in the mouth but this is uncommon. If they occur they can be very sore and unpleasant. Hot or spicy foods are especially difficult to eat. Mouth ulcers can occur with or without the skin rash. In some cases, the gums become red and sore.

Lichen planus of other parts of the body
Most people with lichen planus just have the skin rash and/or mouth involvement. However, in some cases other areas of the body are also affected. These include the following.

• Vulva and vagina of women - lichen planus can cause painless white streaks on the vulva. However, it can also cause painful red sore areas of the vulva and entrance to the vagina. This can be sore, itchy and in severe cases make it very painful to have sex. Scar tissue may also develop which may narrow the entrance to the vagina.
• Penis of men - the typical skin rash may affect the glans of the penis. Also, white patches may develop on the glans (head of the penis).
• Nails - about 1 in 10 people with lichen planus have affected nails. It usually causes minor ridging of the nail. However, severe damage to the nail can occur in some cases.
• The scalp - which can cause patches of baldness.
• Rarely - the oesophagus (gullet), larynx, bladder and anus can be affected

How is lichen planus diagnosed?

In most cases the rash is typical and a doctor can diagnose the condition from the look of the rash. If there is doubt, then a small sample of affected skin can be taken (a biopsy) under local anaesthetic. The biopsy sample is looked at under a microscope. Characteristic changes in the skin can be seen which confirms the diagnosis.

There is no quick cure for lichen planus. However, it is likely to clear in time. Treatment aims to relieve itching and improve the appearance of the rash until it goes away.

• No treatment - is an option if symptoms are mild.
• A steroid cream or ointment - is commonly advised. Steroids reduce inflammation. The effect of steroid creams and ointments are variable. They work in many cases to ease itch, but may not actually clear the rash.
• Steroid pastes or mouth washes may help to ease painful mouth ulcers if they occur.
• A course of steroid tablets may be advised if lichen planus is severe. This may clear, or greatly reduce the rash. Steroid tablets taken for longer than a few weeks are not usually advised due to possible side-effects. Therefore, the rash may re-appear after the tablets are stopped. However, a course of steroid tablets may help 'tide over' a particularly bad spell.
• Acitretin tablets - have been shown to help ease symptoms in some cases.
• Immune suppressant medication - may be advised by a specialist if lichen planus is severe. These include cyclosporin and azothiaprine. These reduce inflammation and are used in a variety of conditions where control of inflammation is difficult. Potential serious side-effects mean that they are not used routinely, but may be advised for people with severe lichen planus.
• PUVA - this is a special 'light therapy' that may be advised by a skin specialist if you have extensive and severe lichen planus.
• Antihistamine medicines - may help ease the itch. A antihistamine that makes you sleepy taken at bedtime may help you to sleep if the itch keeps you awake at night.

Newer 'immune-modulating' creams and ointments such as tacrolimus and pimecrolimus seem to help but further research is needed to confirm their role in treating lichen planus.

• In general, the outlook is good. Lichen planus of the skin usually goes without leaving any ongoing problems.
• Without treatment, about half of cases of lichen planus affecting the skin clear within 6-9 months. The rest usually clear soon after this. It is unusual for the rash to last longer than 18 months. However, lichen planus persists longer in a small number of people who are severely affected. This is mostly in people who develop lichen planus mouth ulcers, and lichen planus of the vulva or penis.
• Treatment can usually ease skin symptoms until the rash clears.
• For lichen planus of the skin, once the rash has cleared, about 1 in 5 affected people have a recurrence sometime in the future. A small number of people have several recurrences.
• If lichen planus affects nails or hair, any damage such as bald patches or destroyed nails is permanent.
• People with lichen planus have a slightly higher than average chance of developing other 'inflammatory' diseases. For example: ulcerative colitis, alopecia areata, vitiligo, dermatomyositis, morphea, lichen sclerosis, and myasthenia gravis. This is probably due to some people being more prone to 'immune' or 'inflammatory' conditions. However, most people with lichen planus do not develop any of these other conditions.
• If painful ulcers develop in the mouth due to lichen planus, then there is higher than average chance of developing cancer of the mouth. Again, most people do not but regular mouth checks from a dentist are advisable.
• If the vulva is badly affected, there is a slight increased risk of developing cancer of the vulva.

Pictures of skin conditions

For a list of internet sites which contain pictures of skin conditions see www.patient.co.uk/showdoc/1097/. The sites listed have not been checked to see if there is a picture of lichen planus, but these sites are large and comprehensive.

© EMIS and PIP 2005   Updated: August 2005