CPD June PJ Online 10/6/10 14:36 Page 36

LEARNING & DEVELOPMENT

CPD

Lichen planus and its management

In a recent letter to The Journal Christine Clark stated that pharmacists
should play a major role in the management of both long- and short-
term skin conditions but that research is needed to identify the types of
dermatological problems commonly presented. In this article she
describes lichen planus and how pharmacists can support sufferers
Reflect

Evaluate Plan

Act

©2006 Galderma S.A. All rights reserved

Reflect on knowledge gaps
1. What is lichen planus?
2. How is it treated?
3. What advice can you give about
managing the condition?

Before reading on, think about how this

article may help you to do your job better.
Lichen planus Typically presents as shiny raised red-purple papules

ICHEN PLANUS (also known as in a net-like pattern of white streaks known of the cheeks and the sides of the tongue.

L lichen ruber or lichen ruber planus)

— a non infectious condition
involving the skin or mucous membranes
— affects up to 2 per cent of people.
Although it is less well known than
psoriasis and eczema, the impact of lichen
planus can be significant. For example, it
has been shown that the condition has a
similar impact on the patient’s quality of
life to that of psoriasis1 and awareness of
the condition and the measures that can be
used to ameliorate it is important for
primary care health professionals.
Clinical presentation
Like psoriasis and eczema, lichen planus
can present in a number of clinical variants.
Typically, it appears as an itchy rash of
small (3 to 5mm diameter), shiny, raised,
reddish-purple (violaceous) papules. The
papules are flat topped and can be covered
as Wickham’s striae.
The rash appears suddenly, commonly
affecting the inside of the wrists, ankles,
elbows and lower back, although other
parts of the body can also be affected. It
can sometimes appear in lines where the
skin has been scratched or cut. The rash
usually lasts for several months and new
lesions can break out while others are
clearing. It can cause intense itching,
particularly at night. Thickened
(hypertrophic) lichen planus affects the
shins, and ring-shaped (annular) lichen
planus affects areas with creases in the
skin, such as the armpits.
About 50 per cent of people with lichen
planus affecting the skin also have oral
involvement. It is also possible to have oral
lichen planus — often diagnosed by dentists
— without the skin being affected. The
most frequently affected areas are the inside
The affected mucosa is usually covered
with painless white streaks in a lace- or
fern-like pattern, but there is also an erosive
form of the condition in which painful,
persistent ulcers occur. Occasionally the
gums are affected and redness and peeling
occur. This is sometimes due to contact
allergy to mercury in amalgam fillings. In
such cases the lichen planus can resolve on
replacing the fillings with a mercury-free
alternative. (Contact allergy should be
confirmed by patch testing.)
Genitals can also be affected by lichen
planus. In men, it can present as purple-
coloured or white ring-shaped patches on
the penis. These are not usually itchy. In
women, vulval lichen planus can range
from white-streaked papules to severe
erosions. Soreness, burning and rawness are
common symptoms in addition to itching
and pain on intercourse (dyspareunia).

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symptoms as much as possible until there

Panel 1: Advice on lichen planus is spontaneous remission — asymptomatic
lichen planus requires no treatment.
● Lichen planus is usually a self-limiting condition. There is a small likelihood of recurrence. There are not many products licensed
● Lichen planus is not contagious and cannot be passed by skin contact or sexual contact. specifically for lichen planus and
● There is no cure but treatment can control the condition (and may clear the skin lesions) until it pharmacists are in a position to advise both
resolves. patients and prescribers on what
● No large randomised controlled clinical trials have been conducted for therapy and several formulations are available. They are also in
treatments may need to be tried. a position to provide advice on potential
● Potent topical corticosteroids are a safe and appropriate treatment for lichen planus, even when side effects of treatments and to give
used on sensitive areas such as the genitals and flexures (eg, armpits). reassurance, for example, where the
● Postinflammatory hyperpigmentation is often an unavoidable effect of the disease; it is not condition necessitates the use of a potent
caused by topical corticosteroids. steroid on genitals.
● Patients should take care to avoid skin damage because new lesions can appear at the sites of
scratches or cuts. Cutaneous lichen planus Mild cases
● Contact with soap, bubble bath, shampoos etc can further irritate the skin. may need treatment for itching — sedating
antihistamines can be taken at night to ease
itching and the resulting sleep disturbance
Reports suggest that more than 50 per cent might indicate a genetic predisposition. The — and patients should also be given advice
of women with oral lichen planus have significance of these observations is not fully about measures to prevent further damage
undiagnosed vulvar lichen planus. understood. Drug-induced rashes that look to inflamed skin, such as avoiding soap and
It is estimated that 10 per cent of lichen like lichen planus are described as harsh detergents.
planus cases involve the nails. lichenoid drug eruptions. They are usually Moisturisers with a good lipid content
Characteristic changes include longitudinal pink or purple flat, scaly patches on the (so not aqueous cream) may soothe the
grooving and ridging, darkening, trunk. This is a rare side effect of a number skin and also help to reduce itching.
thickening and separation of the nail from of drugs including beta blockers, non- However, moderate lichen planus affecting
the nail bed (onycholysis). Lichen planus steroidal anti-inflammatory drugs, the skin is usually treated with very potent
occasionally appears on the scalp where it angiotensin-converting enzyme inhibitors, or potent topical corticosteroids such as
can cause patchy scarring alopecia (ie, hair sulphonylureas, gold, antimalarial agents, clobetasol and fluocinonide, which
loss can be permanent). penicillamine and thiazides. Some drugs, combats both itching and inflammation. As
Lichen planus can occur at any age but such as quinine and thiazide diuretics, have inflammation is suppressed the lesions will
over two thirds of patients are aged been implicated in causing actinic change colour and flatten. Patients should
between 30 and 60 years. No racial trends (sunlight-activated) lichen planus in sun- be advised that once the lesions have
have been noted. exposed sites. Lichenoid drug eruptions changed from red-purple to grey or brown
clear up slowly after the responsible and flattened there will be no further
Causes medicine is discontinued. response to the topical corticosteroid and
The cause is not well understood. Lichen treatment should be discontinued. Such
planus is thought to be the result of a cell- Diagnosis treatment may be needed for up to six
mediated immune response to an induced Lichen planus is diagnosed on the basis of weeks, even though it is with a high
antigenic change in epidermal cells of a examination findings and history. Because potency steroid. It should also be noted that
genetically predisposed individual. of the variable appearance of lichen planus topical steroids will not make any
Autocytotoxic CD8+ T lymphocytes in it can sometimes be confused with planar postinflammatory hyperpigmentation
lesional skin recognise a major warts, some types of eczema or psoriasis, (brown or grey marks) disappear any faster
histocompatibility class I antigen (lichen tinea corporis or pityriasis rosea. For this but will increase the risk of side effects
planus specific antigen; LPSA). The exact reason many patients end up being referred such as thinning of the skin. On the other
nature of this antigen is unknown — it to a dermatologist. The possibility of a hand, patients are sometimes given the
might be an autoreactive peptide or an lichenoid drug eruption also needs to be impression that steroids are dangerous
exogenous antigen such as a drug, contact excluded. Sometimes a biopsy, under local
allergen or virus. The activated T anaesthetic, is taken to confirm the Author Christine Clark will be
lymphocytes are believed to induce diagnosis (there are characteristic available to answer questions
apoptosis of basal keratinocytes. histological changes) and to exclude the online on the topic of this CPD
An association between lichen planus and malignancy.
article until 28 June 2010
hepatitis C has been reported and the onset or
worsening of the condition has been linked to Management
stressful life events. Some patients also have There is no cure for lichen planus and the
a family history of lichen planus, which objective of treatment is to suppress

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CPD June PJ Online 10/6/10 14:36
LEARNING & DEVELOPMENT
CPD
Panel 2: Advice for people with oral lichen planus
● Avoid eating spicy foods and anything
acidic (eg, fruit juices, tomatoes,
strawberries).
● Avoid crispy foods (eg, crusty bread or
crisps.)
● Avoid drinking alcohol, particularly spirits.
● Try sticking to fairly bland food (eg,
porridge, softly boiled eggs, mashed
potatoes etc) when lesions are painful.
● If you cannot keep to your usual
toothpaste, try an alternative like Aloe-
dent, which is mild and non-irritating.
● Keep your mouth as clean as possible but do not brush your teeth more than twice a day.
● If you wish to use a mouthwash choose one that does not contain alcohol (eg, Dentyl).
● Your dentist may want to see you every couple of months if you have erosive oral lichen planus
but be wary of dental hygienists using equipment to polish your teeth — this might cause
damage to your gums.
● Avoid smoking.
Adapted from the UKLP patient information leaflet
to use and pharmacists should try to avoid
inducing under-treatment. Sometimes
products with antibacterials (eg, Trimovate)
are prescribed but there does not seem to
be a rationale for the antibiotic component.
Severe lichen planus (ie, extensive or
painful and erosive disease and nail
destruction) can be treated with oral
corticosteroids (eg, oral prednisolone 20mg
daily for two to six weeks, followed by a
taper). Other treatments that have been
tried (unlicensed indications) include the
topical calcineurin inhibitors tacrolimus
and pimecrolimus, ciclosporin
(1–6mg/kg/day for several months2),
acitretin (30mg/day for eight weeks2) and
methotrexate (1–15mg/week for up to 17
months3). Treatment with ultraviolet light
(UVB, narrow band UVB and PUVA
[psoralen and UVA]) has also been used for
extensive cutaneous disease.
Oral lichen planus Consensus
guidelines published in 2005 recommend
that first-line treatment for oral lichen
planus should be with topical
corticosteroids.4 Agents, such as
betamethasone valerate, clobetasol,
fluocinolone acetonide, fluocinonide and
triamcinolone, formulated in adhesive paste
have been widely used. However, in the
UK, there is no longer a topical steroid
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Mouthwashes can be helpful for a sore
mouth, particularly if used before meals.
Regular use of benzydamine hydrochloride
(0.15 per cent) spray or mouthrinse is an
option. If this is not effective 2 per cent
lidocaine gel may be applied to painful
©2006 Galderma S.A. All rights reserved
areas. An antiseptic mouthwash or gel may
also be recommended, to help to control
dental plaque.
Genital lichen planus Genital disease
is also treated with very potent topical
corticosteroids, such as clobetasol
propionate 0.05 per cent.6 For example, the
dermatology department at Ninewells
Hospital, Dundee, prescribes Dermovate to
be applied daily for a month, then on
alternate days for a month and then twice a
week for a third month. Although data
sheets usually advise against the use of
such potent steroids on the genital area,
dermatologists agree that lichen planus is
one of the few conditions where it is not
only appropriate, but in the case of vulvar
proprietary product formulated in disease, essential to avoid serious
carmellose gelatin paste (ie, Orabase). destructive damage. (The summary of
The available topical steroid products for product characteristics for Dermovate
use on the oral mucosa are hydrocortisone contraindicates its use for “perianal and
oral mucosal tablets (pellets) and genital pruritus” but dermatologists
betametasone 500μg soluble tablets emphasise that genital lichen planus is
dissolved in 10–15 ml of water and used as more than “an itchy bottom”.)
a mouthrinse up to three times a day Hydrocortisone acetate foam used
(unlicensed indication). Metered dose rectally to treat inflammatory bowel disease
inhalers (eg, beclometasone dipropionate can be used inside the vagina (unlicensed
inhaler 100μg and fluticasone 50μg, indication). Steroid suppositories have also
unlicensed indication) have also been used been used vaginally. The treatment should
as mouth sprays, sprayed three or four be used daily at bedtime for two or three
times a day on affected sites.5 months and then twice a week. This helps
Fluorinated steroids (fluocinonide 0.05 to prevent vaginal adhesions.6
per cent and fluocinolone acetonide 0.1 per One small study found that topical
cent) have been found to be effective in the pimecrolimus was well tolerated and
treatment of severe oral lichen planus that effective in most women with genital
has failed to respond to other treatments.4 lichen planus.7
Systemic steroids are generally reserved
for disease that does not respond to topical Outcomes
treatments. Other agents, such as In general, the prognosis for people with
tacrolimus, retinoids and PUVA, are lichen planus is good. Without treatment,
reserved for third-line treatment. about 50 per cent of cases of cutaneous
lichen planus clear within nine months.
Check your learning... Most cases of cutaneous lichen planus
resolve spontaneously within 18 months
available online and usually do not recur. (It is reported that
until 12 July about one in six patients will experience a
2010 recurrence.) Oral disease and erosive
disease of the vulva or penis, however,
tend to be more persistent. Oral lichen
CPD June PJ Online 10/6/10 14:36 Page 39

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Panel 3: Advice for people with genital lichen planus

● Wash with plain warm water (no soap or bubble bath) and use a soap substitute (eg, aqueous
cream).
● Wash your hair over a basin to avoid contact of shampoo with affected skin.
● Apply a plain emollient or aqueous cream liberally before and after urinating.
©2006 Galderma S.A. All rights reserved
● Aqueous cream is more soothing if chilled before application.
● Ice packs (or a bag of frozen peas) can be useful to reduce itching and swelling but should not
be applied directly onto the skin (this can damage skin further).
● Use a good sexual lubricant (eg, Astroglide, V Gel and Sensilube). These products are mucus-
like and moisturising.
● Women should wear stockings instead of tights.
● Go without underwear wherever possible.

Lichen planus 10 per cent of cases involve nails Adapted from the UKLP patient information leaflet

planus is reported to have an average efficacy.Archives of Dermatology
duration of five years but, according to the 1998;134:1521–30.
British Dental Health Foundation, oral 3. Nylander Lundqvist E,Wahlin YB, Hofer PA.
lichen planus generally never goes away. Methotrexate supplemented with steroid ointments
Residual skin marking (post- for the treatment of severe erosive lichen ruber.Acta
inflammatory hyperpigmentation) can Dermato Venereologica 2002;82:63–4.
persist for a long time and can be more 4. Lodi G, Scully C, Carrozzo M, Griffiths M, Sugerman PB
marked in Asian or Afro-Caribbean skin. and Hongprasom K. Current controversies in oral
There is a small risk that long-standing lichen planus: Report of an international consensus
erosive lichen planus can undergo meeting. Part 2. Clinical management and malignant
cancerous changes resulting in oral or transformation. Oral surgery, oral medicine, oral
genital tumours. pathology, oral radiology and endodontics
2005;100:164–78.
Role for pharmacists 5. European Association of Oral Medicine. Oral lichen
In addition to giving advice on treatment, planus. Available at www.eaom.net (accessed on
pharmacists can: 28 May 2010).
6. Lewis FM, Pelisse M.Vulvar lichen planus: clinical
● Explain what is known about lichen aspects and guideline to management. CME
planus (see Panel 1) and encourage Journal of Gynecologic Oncology 2005;10:188–92.
people to seek medical attention 7. Lonsdale-Eccles AA, Velangi S. Topical
● Advise on other measures that might help, pimecrolimus in the treatment of genital lichen
particularly for those with oral (see Panel planus: a prospective case series. British Journal of
2) or genital lichen planus (see Panel 3) Dermatology 2005; 153:390–4.
● Signpost people to patient support groups.
Resources
Signposting ■ Information leaflets on lichen planus are available
■ Useful information can be downloaded from the from the British Association of Dermatologists and
UK Lichen Planus website (www.uklp.org.uk).The from Clinical Knowledge Summaries.
organisation can also provide contact with other
people with lichen planus. Further reading
■ Patients with scalp disease can also be signposted ■ An article by Chuang T-Y, Stitle L. Lichen planus.
to Alopecia UK (www.alopeciaonline.org.uk), (http://emedicine.medscape.com) gives further
which has a network of local groups in the UK. information on histological findings and doses of
third-line agents used. Further details on oral lichen
References planus are also available at this site, in an article
1. Balci DD, Inandi T. Dermatology life quality index authored by Sugerman P and Porter SR.
scores in lichen planus: comparison of psoriasis and ■ Chan ESY,Thornhill M, Zakrzewska JJM.
healthy controls.Turkderm 2008; 42:127–30. Interventions for treating oral lichen planus.
2. Cribier B, Frances C, Chosidow O.Treatment of lichen Cochrane Database of Systematic Reviews 1999,
planus: an evidence-based medicine analysis of Issue 2.Art. No.: CD001168.
● Christine Clark, PhD, FRPharmS, is a
medical writer and chairman of the Skin
Care Campaign.
CPD articles are commissioned by The
Pharmaceutical Journal and are not peer
reviewed.
Act: practice points
Reading is only one way to undertake CPD
and the Society will expect to see various
approaches in a pharmacist’s CPD portfolio.
1. Review your counselling related to
supplies of topical steroids.
2. Speak to your local dentist about oral
lichen planus and his or her
formulations of choice.
3. Are you taking appropriate action
when supplying medicine for an
unlicensed indication? Download
“Fact sheet: five” the Royal
Pharmaceutical Society legal and
ethical advisory service’s
guidance from the Society’s
website.
Evaluate
For your work to be presented as CPD, you
need to evaluate your reading and any
other activities. What have you learnt?
How has it added value to your practice?
(Have you applied this learning or had any
feedback?) What will you do now and how
will this be achieved?
Record
Consider making this activity one of your
nine CPD entries this year.

June 2010 | PJ Online 4