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LICHEN PLANUS

New treatment for oral lichen planus now available, using a special oral adaptor with the Exsys 308 Excimer Light - see pictures below.

Cause

 

The cause of Lichen Planus is unknown in the majority of individuals. In a small proportion of patients, however, the following causes can be traced.

 

1. Medicines: the most common being some high blood pressure tablets, and remedies for diabetes, joint pains and TB. (See below for list of drugs causing lichen planus).  For this reason, always provide a full list of medicines you have taken prior to the onset of your rash.

 

2. Paraphenelenediamine. This is a chemical found in photographic chemical developer.

 

3. Bone marrow transplantation. This is a very rare procedure performed for unusual disorders.


 

Appearance

 
Lichen planus is characterised by the following features:

 

  • small raised bumps (pinhead to 4mm in diameter) 

  • purplish colour

  • many sided (polygonal)

  • smooth topped

  • shiny

  • itchy

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The bumps may have whitish lines called Wikham's striae

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Typical sites:

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  • wrists

  • lower back (sacrum)

  • around ankles

  • inside the mouth

  • nails (typical appearance is called a pterigium)

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On lower legs, spots may be larger and thickened.

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Features at special sites:

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1. the mouth: Whitish or purplish streaks may be seen on the inner aspect of the cheeks or lips. Ulceration (breaking down of the surface) at this site should always be reported to your dermatologist as there is a 1% chance of malignancy when this happens. In the early stages, this complication is curable.

 

2. the scalp: Patches of hair loss may be seen. This underlying skin retains its characteristic purplish colour.

 

3. the nails: the surface of the nails may become irregular with streaks running along the length of the nail or across the nail. A characteristic deformity which occurs almost solely in Lichen planus is called a Pterygium, in which the skin around the nail becomes continuous with the floor of the nail (nail bed). The actual nail is lost over this affected area. See picture above.

 

4. Genitalia: In males, the head or shaft of the penis and in females, the vulva or labia may be involved.

Lichen Planus is not a contagious disease. It is not transmitted from one person to another by contact or by sharing utensils, towels, clothing etc. In some individuals it is made worse by sun exposure. Stress tends to aggravate the condition but is not responsible for causing the eruption.

 

Dermatoscopic image of lichen planus showing white steaks (Wikham's striae) and radial blood vessels.

Source: JAMA network

Pterygium - a typical nail change seen in lichen planus where the nail fold fuses with the nail bed and becomes continuous with it.

Source: Ourdermatology online

Treatment

 

The treatment of Lichen Planus is symptomatic. A cure has not as yet been discovered. Untreated, the rash often goes on for more than a year, but eventually subsides spontaneously. The purpose of treatment is to suppress the rash a lot sooner. It is not unusual for the rash to heal with very dark pigmentation, especially in pigmented individuals.

 

1. Topical corticosteroids

 

Popularly referred to as "cortisone creams". Reasonably strong creams or ointments are used. On the genitalia, however, one has to exercise caution with the use of very strong steroids.

Examples of steroids used on the skin include Diprosone, Betnovate, Synalar, Nerisone, Elocon and Advantan. Very strong steroids include Dermovate, Diprolene and Nerisone Forte Fatty Ointment. The latter group should be reserved for very resistant, thick areas of involvement such as on the legs. One should never loose sight of the side effects of these preparations.

 

2. Intralesional steroids

 

This modality implies the injection of steroid preparations into individual spots. Only those areas resistant to topical steroids are treated with this regime. The legs are a favourite site for this form of treatment.

 

3. Oral steroids

 

In view of the nature of side effects associated with internal use, this route of administration is reserved only for very severe Lichen Planus affecting large areas of the body .

 

4. Etretinate (Tigason)

 

This very expensive medication, also with many side effects, has been used successfully in patients with extensive Lichen Planus.

 

5. Cyclosporin

 

The contents of the Cyclosporin capsule is dissolved in water and the mixture is swished around the mouth for about 5 minutes but not swallowed. This is excellent for lichen planus of the mouth.

 

6. Very mild Lichen Planus may of course be left alone until spontaneous resolution takes place

 

7. Oral Antihistamines

These may be used to relieve the associated itching. 

Examples include Aterax, Tinset, Phenergan, Zyrtec, Clarityne, Telfast and Kestine.

The last four do not induce drowsiness.

 

8.  Metronidazole tablets.  More recently metronidazole has been hailed as an excellent treatment for Lichen Planus.  Our use of this product has produced results equivalent to those reported in the American Academy Journal.    This medication is taken orally and takes about one to three months to achieve control of the condition.

 

9.  Excimer laser

Recently the excimer laser has been found to be particularly beneficial for the treatment of lichen planus.  Small areas of involvement are ideally suited to this form of treatment.  A novel oral adaptor has been developed by GME (Germal Medical Engineering) which allows the oral mucosa (inside of the cheeks, gums, tongue, palate etc) to be treated. 

 

The special oral adaptor of the ExSys 308 Excimer Light device, used to treat oral lichen planus.

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This was the result after just one single treatment.

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The special oral adaptor of the ExSys 308 Excimer Light device, used to treat oral lichen planus.

Treatment of oral lichen planus

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Oral lichen planus is jointly managed by dermatologists, dentists, ENT surgeons and maxilofacial surgeons. 

Management includes the following measure:

 

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For severe oral lichen planus, the following additional measures may be considered:

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Further reading:  

 

1.  https://dermnetnz.org/topics/oral-lichen-planus

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2.  Zundell MP, Kaminetsky J, Lebwohl M, Gottlieb AB. Successful Treatment of Lichen Planus With Oral Upadacitinib. J Drugs Dermatol. 2023 Oct 1;22(10):1058-1060. doi: 10.36849/JDD.7272. PMID: 37801537.

List of drugs causing lichen planus

 

    Phenytoin

    Oral contraceptives

    Gold

    Isoniazide

    Hydrochlorothiazide (HCTZ Diuretics)

    Atabrine (Antimalarials)

    Quinidine

    Lasix

    

    (ref:  http://www.dermadoctor.com)

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Other medications that have been reported in association with lichenoid drug eruptions include:

  • Tumour necrosis factor antagonists such as infliximab, etanercept and adalimumab

  • Imatinib mesylate (tyrosine kinase inhibitor)

  • Misoprostol (prostaglandin E1 agonist)

  • Sildenafil citratus (Viagra™)

  • Vaccines (especially those for herpes zoster and influenza).

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Source of above list: NZ dermnet

Further reading:

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https://dermnetnz.org/topics/lichen-planus

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