Lichen Planus

Dermatology

Clinicals - History

Fact Explanation
There are Violaceous, itchy papules occurring at the ventral aspect of wrists and legs . On the palms and soles, there are yellow colored, firm papules. This is considered to be an Immune mediated disease. CD8+ T cells recognize antigens on basal keratinocytes and cause lysis of the cells.

Note:There are subtypes/variants in this disease(Annular,Atrophic,Bullous,Follicular, Hypertrophic,Ulcerative) and specific features vary according to the varients.
There are Violaceous, itchy papules occurring at the ventral aspect of wrists and legs . On the palms and soles, there are yellow colored, firm papules.
This is considered to be an Immune mediated disease. CD8+ T cells recognize antigens on basal keratinocytes and cause lysis of the cells.

Note:There are subtypes/variants in this disease(Annular,Atrophic,Bullous,Follicular, Hypertrophic,Ulcerative) and specific features vary according to the varients.
Asymptomatic, white colored, lacy network or papules arise on the buccal mucosa, tongue, gums and lips This is present in 50% of the patients.Also, this may be the only presenting feature.
Desquamative gingivitis results in diffuse inflammation and peeling of the gums.
As a complication, the ulcerative form in the mouth can give rise to Squamous cell carcinoma.
Asymptomatic, white colored, lacy network or papules arise on the buccal mucosa, tongue, gums and lips
This is present in 50% of the patients.Also, this may be the only presenting feature.
Desquamative gingivitis results in diffuse inflammation and peeling of the gums.
As a complication, the ulcerative form in the mouth can give rise to Squamous cell carcinoma.
Nail changes (longitudinal grooves/ destruction of nail and nail bed) The damage is permanent .Nail damage and epithelial growth on nails(causing Pterygium) can be seen. There may be onycholysis present. There may be shedding, arrested growth, or total disappearance of the nail. Nail changes (longitudinal grooves/ destruction of nail and nail bed)
The damage is permanent .Nail damage and epithelial growth on nails(causing Pterygium) can be seen. There may be onycholysis present. There may be shedding, arrested growth, or total disappearance of the nail.
Patchy alopecia This is a permanent type of alopecia(cicatricial alopecia).This is due to the fibrosis accompanying inflammation.It results in damaging the hair follicle. Patchy alopecia
This is a permanent type of alopecia(cicatricial alopecia).This is due to the fibrosis accompanying inflammation.It results in damaging the hair follicle.
Painless or painful whitish lesions with inflammation in genitalia(vulval/ vaginal/Penile) In Vulval lichen planus, there are painless, white colored streaks.In the Erosive type, the mucosa of the labia minora and introitus become bright red in color due to inflammation. The labia minora can get adhered to each other or to the labia majora .This type is painful and can interfere with intercourse.
In Vaginal lichen planus, it causes a desquamative vaginitis, resulting in a vaginal discharge. There is also contact bleeding present.
In Penile lichen planus,Papules are arranged as a ring arround the glans.This is the commonest presentation.
Painless or painful whitish lesions with inflammation in genitalia(vulval/ vaginal/Penile)
In Vulval lichen planus, there are painless, white colored streaks.In the Erosive type, the mucosa of the labia minora and introitus become bright red in color due to inflammation. The labia minora can get adhered to each other or to the labia majora .This type is painful and can interfere with intercourse.
In Vaginal lichen planus, it causes a desquamative vaginitis, resulting in a vaginal discharge. There is also contact bleeding present.
In Penile lichen planus,Papules are arranged as a ring arround the glans.This is the commonest presentation.
Chronic course with changes in the lesions The lesions lasts for months to years(Eruptions last about a year and hypertrophic variant lasts longer).
As the lesions resolve, hyper-pigmented( Brown/ gray colored ) discrete macules are develop.
Chronic course with changes in the lesions
The lesions lasts for months to years(Eruptions last about a year and hypertrophic variant lasts longer).
As the lesions resolve, hyper-pigmented( Brown/ gray colored ) discrete macules are develop.
Drug history It tends to cause asymptomatic or itchy purple colored,flat papules on trunk and oral mucosa.The common drugs are: Gold, hydroxychloroquine,Captopril,quinine,thiazide diuretics, Drug history
It tends to cause asymptomatic or itchy purple colored,flat papules on trunk and oral mucosa.The common drugs are: Gold, hydroxychloroquine,Captopril,quinine,thiazide diuretics,
Past history or family history of auto-immune diseases There may be multiple autoimmune diseases present in one patient.Diseases such as Alopecia areata, vitiligo, ulcerative colitis and contact allergy to Mercury( in oral lichen planus) are common Past history or family history of auto-immune diseases
There may be multiple autoimmune diseases present in one patient.Diseases such as Alopecia areata, vitiligo, ulcerative colitis and contact allergy to Mercury( in oral lichen planus) are common
Associated features of Hepatitis C infection Lichen planus is not the result of Hepatitis per-Se but it is observed in patients with Hep-C.This is probably due to immune related molecular mimicry. Associated features of Hepatitis C infection
Lichen planus is not the result of Hepatitis per-Se but it is observed in patients with Hep-C.This is probably due to immune related molecular mimicry.
Recurrence Recurrence occur due to its autoimmune etiology.This occurs in one in six patients. Recurrence
Recurrence occur due to its autoimmune etiology.This occurs in one in six patients.

Clinicals - Examination

Fact Explanation
Multiple, well demarcated violaceous papules with flat surfaces,and polygonal in shape.Common sites are wrists and ankles. When the lesions are examined closely, there is a streaky white colored pattern on the surface called Wickham's striae. Multiple, well demarcated violaceous papules with flat surfaces,and polygonal in shape.Common sites are wrists and ankles.
When the lesions are examined closely, there is a streaky white colored pattern on the surface called Wickham's striae.
Nail changes (longitudinal grooves/ destruction of nail and nail bed) This is permanent . Nail damage and epithelial growth on nails(causing Pterygium) can be seen. There may be onycholysis present. There may be shedding, arrested growth, or disappearance of the nail. Nail changes (longitudinal grooves/ destruction of nail and nail bed)
This is permanent . Nail damage and epithelial growth on nails(causing Pterygium) can be seen. There may be onycholysis present. There may be shedding, arrested growth, or disappearance of the nail.
Patchy alopecia This is a permanent type of alopecia(cicatricial alopecia).This is due to the fibrosis accompanying inflammation, that results in damaging the hair follicle. Patchy alopecia
This is a permanent type of alopecia(cicatricial alopecia).This is due to the fibrosis accompanying inflammation, that results in damaging the hair follicle.
Painless or painful whitish lesions with inflammation in genitalia(vulval/ vaginal/Penile) In Vulval lichen planus, there are painless, white colored streaks present.In the Erosive type, the mucosa of the labia minora and introitus become bright red color due to inflammation. The labia minora can get adhered to each other or to the labia majora .This type is painful and can interfere with intercourse.
In Vaginal lichen planus, it causes a desquamative vaginitis, resulting in a vaginal discharge. There is also contact bleeding present.
In Penile lichen planus,Papules are arranged as a ring arround the glans.This is the commonest presentation.
Painless or painful whitish lesions with inflammation in genitalia(vulval/ vaginal/Penile)
In Vulval lichen planus, there are painless, white colored streaks present.In the Erosive type, the mucosa of the labia minora and introitus become bright red color due to inflammation. The labia minora can get adhered to each other or to the labia majora .This type is painful and can interfere with intercourse.
In Vaginal lichen planus, it causes a desquamative vaginitis, resulting in a vaginal discharge. There is also contact bleeding present.
In Penile lichen planus,Papules are arranged as a ring arround the glans.This is the commonest presentation.
signs suggestive of auto-immune diseases There may be multiple autoimmune diseases present in one patient.Diseases such as Alopecia areata, vitiligo(hypeopigmented macules) , ulcerative colitis(Aphthous ulcer,uveitis, Episcleritis, arthritis, Sacroiliitis,
Erythema nodosum,Pyoderma gangrenosum,Clubbing)
and contact allergy to Mercury( in oral lichen planus)
signs suggestive of auto-immune diseases
There may be multiple autoimmune diseases present in one patient.Diseases such as Alopecia areata, vitiligo(hypeopigmented macules) , ulcerative colitis(Aphthous ulcer,uveitis, Episcleritis, arthritis, Sacroiliitis,
Erythema nodosum,Pyoderma gangrenosum,Clubbing)
and contact allergy to Mercury( in oral lichen planus)
Associated features of Hepatitis C infection Lichen planus is not the result of Hepatitis per-Se but it is observed in patients with Hep-C.This is probably due to immune related molecular mimicry. Features of complicated Hep-C ex-cirrhosis(ascitis, Jaundice) can be observed. Associated features of Hepatitis C infection
Lichen planus is not the result of Hepatitis per-Se but it is observed in patients with Hep-C.This is probably due to immune related molecular mimicry. Features of complicated Hep-C ex-cirrhosis(ascitis, Jaundice) can be observed.

Investigations - Diagnosis

Fact Explanation
Skin biopsy This is usually a clinical diagnosis, but a biopsy will conform the diagnosis.
A punch biopsy is taken from the affected area (skin/mouth).Typical “saw-tooth” pattern of epidermal hyperplasia, hyperparakeratosis vacuolar changes in basal layer,and T-Cell infiltration at the dermal-epidermal junction can be identified.
Skin biopsy
This is usually a clinical diagnosis, but a biopsy will conform the diagnosis.
A punch biopsy is taken from the affected area (skin/mouth).Typical “saw-tooth” pattern of epidermal hyperplasia, hyperparakeratosis vacuolar changes in basal layer,and T-Cell infiltration at the dermal-epidermal junction can be identified.
Direct immunofluorescence study In direct immunofluorescence studies immunoglobulins were deposited at the cytoid bodies and fibrin was deposited at dermoepidermal junction. This test may be helpful in diagnosing patients with inadequate clinical and histological evidence. Direct immunofluorescence study
In direct immunofluorescence studies immunoglobulins were deposited at the cytoid bodies and fibrin was deposited at dermoepidermal junction. This test may be helpful in diagnosing patients with inadequate clinical and histological evidence.

Management - Supportive

Fact Explanation
Patient education Inform the patient about the nature of the disease, complications and prognosis.LP is a self limited condition and patient should be aware of it. Patient education
Inform the patient about the nature of the disease, complications and prognosis.LP is a self limited condition and patient should be aware of it.
Skin and genital area management Wash with plain warm water avoid soap/shampoo,. Use a plain emollient/ aqueous cream and use a good lubricant in intercourse.
Try to wear light undergarments as possible,.
Visit a dermatologist for further issues.

[Note: Management of skin in both genital and other areas is similar in relation to cleaning]
Skin and genital area management
Wash with plain warm water avoid soap/shampoo,. Use a plain emollient/ aqueous cream and use a good lubricant in intercourse.
Try to wear light undergarments as possible,.
Visit a dermatologist for further issues.

[Note: Management of skin in both genital and other areas is similar in relation to cleaning]
Select suitable food Avoid spices and acidic food Select suitable food
Avoid spices and acidic food
Avoid alcohol, tobaco Avoid taking alcohol, tobaco or spirits because it irritates , reduces healing rate and increases the risk of malignency . Use a mouthwash which doesn't contain alcohol / or use chlorhexidine mouthwash Avoid alcohol, tobaco
Avoid taking alcohol, tobaco or spirits because it irritates , reduces healing rate and increases the risk of malignency . Use a mouthwash which doesn't contain alcohol / or use chlorhexidine mouthwash
Improve oral hygiene Use a toothpaste that is mild and non irritating.
Regular visits to the dentist helps in maintaining gum health and he can identify any pre-malignent lesions
Improve oral hygiene
Use a toothpaste that is mild and non irritating.
Regular visits to the dentist helps in maintaining gum health and he can identify any pre-malignent lesions

Management - Specific

Fact Explanation
Topical steroids These agents relive the inflammation and reduce the size of the plaques.
Topical high-potency corticosteroids and intralesional corticosteroids are commonly used to minimize scaring alopecia.
Topical steroids
These agents relive the inflammation and reduce the size of the plaques.
Topical high-potency corticosteroids and intralesional corticosteroids are commonly used to minimize scaring alopecia.
Systemic steroids This method is recommended only for severe conditions such as nail lesions or erosive oral lesions. Systemic steroids
This method is recommended only for severe conditions such as nail lesions or erosive oral lesions.
Photochemotherapy This reduces pruritus and improve healing. Photochemotherapy
This reduces pruritus and improve healing.
Oral cyclosporin/ or Acitretin This is considered in patients with severe or resistant types., Oral cyclosporin/ or Acitretin
This is considered in patients with severe or resistant types.,
Antihistamines These drugs reduce the itch ,and improves healing and well being Antihistamines
These drugs reduce the itch ,and improves healing and well being
intralesional triamcinolone acetonide Hypertrophic lesions are treated with intralesional injections intralesional triamcinolone acetonide
Hypertrophic lesions are treated with intralesional injections
For genital lichen planus Triamcinolone ointment is firstline treatment. Topical tacrolimus and clobetasol are used in vulvovaginal (erosive lichen planus) LP.Topical lidocaine relives pain. For genital lichen planus
Triamcinolone ointment is firstline treatment. Topical tacrolimus and clobetasol are used in vulvovaginal (erosive lichen planus) LP.Topical lidocaine relives pain.
High-potency topical steroids This is a very effective treatment and it is used as first line treatment for oral LP.This is also used in mucosal erosive lichen planus. High-potency topical steroids
This is a very effective treatment and it is used as first line treatment for oral LP.This is also used in mucosal erosive lichen planus.
Systemic corticosteroids(oral prednisone) This is only used in severe oral lichen planus and LP with other mucocutaneous sites. Systemic corticosteroids(oral prednisone)
This is only used in severe oral lichen planus and LP with other mucocutaneous sites.
Topical calcineurin inhibitors, such as tacrolimus/ pimecrolimus These are second-line therapy for oral lesions. Topical calcineurin inhibitors, such as tacrolimus/ pimecrolimus
These are second-line therapy for oral lesions.
Carbon-dioxide laser evaporation If the condition is not responding to topical corticosteroids, this method can induce a long-term remission of symptoms.

It can also be considered as first-line measure in patients with painful oral lesions.
Carbon-dioxide laser evaporation
If the condition is not responding to topical corticosteroids, this method can induce a long-term remission of symptoms.

It can also be considered as first-line measure in patients with painful oral lesions.
Tetracycline This was found to be useful in the treatment of gingival lesions., Tetracycline
This was found to be useful in the treatment of gingival lesions.,
Metronidazole Oral lesions show a good response to this drug., Metronidazole
Oral lesions show a good response to this drug.,

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