Lichen Planus: Symptoms, Causes & Treatment Guide

What Is Lichen Planus?

Lichen planus is a chronic inflammatory condition affecting the skin and mucous membranes, characterized by itchy, flat-topped purple papules on the skin and white lace-like patterns in the mouth. It affects approximately 0.5-2% of the population worldwide and is most common in adults aged 30-60.

Lichen planus, also known as lichen ruber planus, is an inflammatory condition that occurs when the immune system mistakenly attacks cells in the skin or mucous membranes. The name comes from the Greek word "lichen," referring to tree moss, and the Latin "planus" meaning flat - accurately describing the flat-topped appearance of the skin lesions.

The condition can affect various parts of the body, including the skin (cutaneous lichen planus), mouth (oral lichen planus or OLP), genitals (genital lichen planus), scalp (lichen planopilaris), and nails. While the exact cause remains unknown, researchers believe it involves an abnormal immune response where T-lymphocytes (a type of white blood cell) attack the basal layer of the skin or mucous membranes.

Unlike many skin conditions, lichen planus is not contagious - you cannot catch it from or spread it to another person through physical contact, sharing items, or any other means. It is also not caused by any infection, allergy, or lifestyle choice. The condition affects women slightly more often than men, and while it can occur at any age, it most commonly develops between the ages of 30 and 60.

What causes lichen planus?

The exact cause of lichen planus remains unknown, but it is classified as an immune-mediated inflammatory condition. This means the body's immune system becomes activated against its own cells, specifically targeting keratinocytes (skin cells) in the basal layer of the epidermis. Several factors have been associated with triggering or worsening the condition:

• Hepatitis C infection: Multiple studies have shown a significant association between hepatitis C and lichen planus, particularly oral forms
• Medications: Certain drugs can cause lichenoid drug eruptions that closely resemble lichen planus, including NSAIDs, beta-blockers, ACE inhibitors, antimalarials, and some antibiotics
• Dental materials: Amalgam fillings and other dental materials have been linked to oral lichen planus in some patients
• Stress: Psychological stress may trigger or exacerbate symptoms in some individuals
• Genetic factors: While not directly inherited, there may be a genetic predisposition to developing the condition

The Koebner phenomenon is also observed in lichen planus - this means new lesions can develop at sites of skin injury or trauma. This is why scratching existing lesions can lead to the development of new ones in previously unaffected areas.

What Are the Symptoms of Lichen Planus?

The classic symptoms of lichen planus include itchy, flat-topped purple or reddish-purple bumps on the skin, white lace-like patterns (Wickham striae) in the mouth, and intense itching. Symptoms vary depending on the location affected, with skin lesions being most itchy and oral lesions causing burning or pain.

Lichen planus symptoms develop gradually over one to several weeks and can vary significantly depending on which body areas are affected. The condition is characterized by the "6 Ps" that dermatologists use to identify it: Purple, Polygonal (many-sided), Planar (flat-topped), Pruritic (itchy) Papules and Plaques. Understanding these symptoms is crucial for early recognition and treatment.

Cutaneous (Skin) Lichen Planus

Skin involvement is one of the most recognizable forms of lichen planus. The lesions typically appear as small, raised, flat-topped bumps that range from 2-10 millimeters in size. On lighter skin, these papules appear shiny and purplish-pink to reddish-purple. On darker skin tones, the lesions may appear darker brown, grayish-brown, or hyperpigmented.

The most common locations for skin lichen planus include the inner wrists, forearms, ankles, lower legs, and lower back, though lesions can appear anywhere on the body. A key diagnostic feature is the presence of Wickham striae - fine white lines visible on the surface of the papules that create a lace-like or net-like pattern. The itching associated with cutaneous lichen planus can range from mild to extremely intense and is often worse at night.

Over time, individual papules may merge together to form larger, scaly plaques, particularly on the lower legs where the condition can become thick and hypertrophic. After the active phase resolves, the skin often shows post-inflammatory hyperpigmentation - brownish discoloration that can persist for months or even years.

Oral Lichen Planus (OLP)

Oral lichen planus is the most common form, affecting approximately 1-2% of the population. It presents as white, lacy, net-like patterns (reticular pattern) on the inner cheeks, tongue, gums, and other oral mucous membranes. These white lines are also called Wickham striae and are often arranged in a distinctive symmetrical pattern.

While the reticular (white lacy) form is usually asymptomatic, oral lichen planus can also present as red, erosive lesions that cause significant pain, burning sensations, and sensitivity to spicy or acidic foods. The erosive form can make eating and drinking uncomfortable and may significantly impact quality of life. Some patients experience both forms simultaneously.

Genital Lichen Planus

Genital involvement can occur in both men and women and may present similarly to oral lichen planus with white striae or erosive, painful lesions. In women, it commonly affects the vulva and vagina, causing itching, burning, pain during intercourse, and vaginal discharge. In men, it typically affects the glans penis and may cause similar symptoms.

Genital lichen planus can be particularly distressing due to its impact on sexual function and quality of life. The erosive form can lead to scarring and anatomical changes if not properly treated. Many patients with genital lichen planus also have oral involvement, so a thorough examination of both areas is recommended.

Lichen Planopilaris (Scalp)

When lichen planus affects the hair follicles on the scalp, it is called lichen planopilaris. This form causes red, scaly patches around hair follicles, followed by destruction of the follicle and permanent, scarring hair loss (cicatricial alopecia). Patients often experience itching, burning, and tenderness of the scalp.

Early treatment is crucial for lichen planopilaris as the hair loss that occurs is irreversible. A variant called frontal fibrosing alopecia primarily affects the hairline, causing gradual recession of the frontal hairline and eyebrows, and is more common in postmenopausal women.

Nail Lichen Planus

Approximately 10% of patients with lichen planus develop nail involvement. The nails may show longitudinal ridging, thinning, splitting, or complete nail loss. In severe cases, scarring can occur, leading to permanent nail damage. The condition can affect both fingernails and toenails.

How Is Lichen Planus Diagnosed?

Lichen planus is typically diagnosed through clinical examination by a dermatologist who can identify the characteristic appearance. A skin biopsy confirms the diagnosis by showing specific microscopic features. Additional tests may include dermoscopy, hepatitis C screening, and patch testing for contact allergies.

Diagnosing lichen planus usually begins with a thorough clinical examination by a dermatologist or other healthcare provider. The characteristic appearance of the lesions - particularly the shiny, flat-topped purple papules with Wickham striae - is often distinctive enough for an experienced clinician to make a clinical diagnosis. However, definitive diagnosis typically requires histopathological confirmation through a skin biopsy.

Clinical Examination

During the examination, your doctor will carefully inspect the affected areas and look for the classic features of lichen planus. They will use a dermatoscope - a handheld magnifying device with a light - to examine the lesions more closely. Dermoscopy can reveal the characteristic Wickham striae and other features that support the diagnosis.

Your doctor will also examine other common sites of involvement, including the mouth and genitals, even if you haven't noticed symptoms in these areas. A comprehensive history will be taken, including questions about medications you're taking, as drug-induced lichenoid reactions can closely mimic lichen planus.

Skin Biopsy

A skin biopsy is often performed to confirm the diagnosis. This involves removing a small sample of affected skin under local anesthesia, which is then examined under a microscope. The histopathological features of lichen planus are distinctive and include:

• Interface dermatitis: Inflammatory cells attacking the junction between the epidermis and dermis
• Civatte bodies: Dead keratinocytes (colloid or apoptotic bodies)
• Band-like lymphocytic infiltrate: A dense band of lymphocytes along the dermal-epidermal junction
• Hypergranulosis: Thickening of the granular layer, creating the Wickham striae
• Saw-tooth pattern: Irregular acanthosis (thickening of the epidermis)

Additional Tests

Depending on your clinical presentation, your doctor may recommend additional tests:

• Hepatitis C testing: Recommended for all patients with lichen planus due to the established association
• Hepatitis B testing: May also be considered in some regions
• Patch testing: If contact allergy is suspected as a trigger
• Blood tests: To rule out other conditions and check liver function
• Direct immunofluorescence: To distinguish from autoimmune blistering diseases if needed

How Is Lichen Planus Treated?

The first-line treatment for lichen planus is potent topical corticosteroids, which reduce inflammation and relieve itching. For oral lichen planus, corticosteroid gels or mouthwashes are used. Severe or widespread cases may require oral corticosteroids, phototherapy, or immunosuppressive medications such as methotrexate or cyclosporine.

Treatment for lichen planus aims to reduce symptoms, speed healing, and prevent complications. Since cutaneous lichen planus often resolves spontaneously within 1-2 years, treatment focuses on managing symptoms during the active phase. However, oral and genital forms may require longer-term management as they tend to be more persistent.

Topical Treatments

Topical corticosteroids are the mainstay of treatment for lichen planus. For skin lesions, potent to superpotent topical steroids (such as clobetasol propionate or betamethasone dipropionate) are typically prescribed. These medications work by suppressing the inflammatory response and reducing itching. They should be applied thinly to affected areas once or twice daily, following your doctor's instructions.

For sensitive areas such as the face, genitals, or skin folds, milder corticosteroids or non-steroidal alternatives may be recommended to avoid skin thinning and other side effects. Calcineurin inhibitors such as tacrolimus ointment or pimecrolimus cream are effective alternatives that don't carry the risk of skin atrophy associated with long-term steroid use.

For oral lichen planus, treatment options include:

• Corticosteroid gels or ointments: Applied directly to oral lesions (e.g., fluocinonide gel, clobetasol gel)
• Corticosteroid mouthwashes: Dexamethasone or triamcinolone rinses for widespread oral involvement
• Tacrolimus ointment: Effective for erosive oral lichen planus
• Anesthetic mouthwashes: For pain relief during meals

Systemic Treatments

For severe, widespread, or treatment-resistant lichen planus, systemic (whole-body) treatments may be necessary:

Oral corticosteroids such as prednisone can provide rapid relief for severe flares. However, due to significant side effects with long-term use, they are typically prescribed for short courses (2-6 weeks) with gradual tapering. Oral steroids are particularly useful for acute severe presentations or when topical treatment is impractical due to the extent of involvement.

Phototherapy (light therapy) can be effective for widespread cutaneous lichen planus. Options include narrowband UVB (NB-UVB) and PUVA (psoralen plus UVA). Treatment typically involves 2-3 sessions per week for several months. Phototherapy works by suppressing the immune response in the skin and can help clear lesions and relieve itching.

Immunosuppressive medications may be considered for severe or refractory cases:

• Methotrexate: Weekly doses for resistant cases
• Cyclosporine: Effective but reserved for severe cases due to side effects
• Mycophenolate mofetil: An alternative immunosuppressant
• Azathioprine: Another option for steroid-sparing treatment

Retinoids such as acitretin or isotretinoin may be helpful for some patients, particularly those with hypertrophic (thickened) lesions. These vitamin A derivatives help normalize skin cell growth and reduce inflammation.

Treatment for Specific Forms

Lichen planopilaris (scalp): Early aggressive treatment is crucial to prevent permanent hair loss. Options include potent topical steroids, intralesional steroid injections, and oral medications such as hydroxychloroquine, doxycycline, or mycophenolate mofetil.

Nail lichen planus: Treatment is challenging and may include intralesional corticosteroid injections into the nail matrix, potent topical steroids applied under occlusion, or systemic therapy for severe involvement.

Genital lichen planus: Requires careful management with medium-potency topical steroids or calcineurin inhibitors. Regular follow-up is important, and patients should be educated about the condition and its management.

What Can I Do to Manage Lichen Planus at Home?

Self-care for lichen planus includes avoiding scratching, managing stress, using gentle skincare products, avoiding triggers like spicy foods for oral lichen planus, and protecting skin from injury. Good oral hygiene is essential for oral lichen planus, and regular monitoring is important.

While medical treatment is usually necessary for lichen planus, there are several things you can do at home to help manage symptoms, prevent flare-ups, and support your overall skin health. These self-care measures can complement your prescribed treatments and improve your quality of life.

General Skin Care

Protecting your skin from trauma is important because of the Koebner phenomenon - new lesions can develop at sites of skin injury. Avoid scratching itchy lesions, as this can worsen the condition and lead to new lesions developing. Keep your nails short and consider wearing cotton gloves at night if you tend to scratch in your sleep.

Use gentle, fragrance-free skincare products to avoid irritating the skin. Mild, pH-balanced soaps or soap-free cleansers are preferable. After bathing, pat skin dry gently rather than rubbing, and apply an emollient (moisturizer) while skin is still slightly damp to lock in moisture.

Managing Triggers

Identifying and avoiding potential triggers can help reduce flare-ups. Common triggers include:

• Stress: Practice stress-reduction techniques such as meditation, yoga, deep breathing exercises, or regular physical activity
• Skin injury: Protect your skin from cuts, scrapes, and other trauma
• Sun exposure: While some patients benefit from controlled sun exposure, others may experience worsening - observe how your skin responds
• Certain medications: Discuss with your doctor if you suspect a medication is triggering your symptoms
• Heat and sweating: Wear loose, breathable clothing and avoid prolonged exposure to extreme heat

Oral Lichen Planus Self-Care

For oral lichen planus, good oral hygiene is essential. Brush your teeth gently twice daily with a soft-bristled toothbrush and use a mild, alcohol-free toothpaste (sodium lauryl sulfate-free products may be less irritating). Floss daily and see your dentist regularly for check-ups.

Dietary modifications can help reduce discomfort:

• Avoid spicy, acidic, or rough-textured foods that may irritate oral lesions
• Reduce consumption of citrus fruits, tomatoes, and vinegar-based dressings
• Limit alcohol consumption, which can irritate the mouth
• Quit smoking, as tobacco use can worsen oral lichen planus
• Drink plenty of water to keep the mouth moist

If you have dental amalgam fillings and your oral lichen planus is in close contact with them, discuss with your doctor or dentist whether replacement with alternative materials might be helpful - though this is not always necessary or beneficial.

When Should You See a Doctor for Lichen Planus?

See a doctor if you notice persistent itchy purple bumps on your skin, white patches or painful sores in your mouth, unexplained genital symptoms, or hair loss. Urgent evaluation is needed for rapidly worsening symptoms, signs of infection, or difficulty eating or drinking due to oral pain.

If you suspect you have lichen planus or notice any of the characteristic symptoms described in this article, it's important to seek medical evaluation. Early diagnosis and treatment can help manage symptoms more effectively and prevent complications, particularly for scalp involvement where early treatment can prevent permanent hair loss.

Reasons to see a doctor

You should contact a healthcare provider - typically a dermatologist for skin symptoms, a dentist or oral medicine specialist for mouth symptoms, or a gynecologist/urologist for genital symptoms - if you experience:

• Persistent itchy purple or reddish-purple bumps on your skin that don't improve with over-the-counter treatments
• White patches, lines, or painful sores inside your mouth
• Unexplained genital itching, pain, or sores
• Hair loss, particularly with scalp itching, burning, or tenderness
• Changes in your nails such as ridging, thinning, or splitting
• Worsening of existing lesions despite treatment

For ongoing oral lichen planus, regular monitoring (typically every 6-12 months) is recommended due to the small risk of malignant transformation. Your healthcare provider will advise you on the appropriate follow-up schedule based on your individual situation.

What Are the Possible Complications of Lichen Planus?

Complications of lichen planus include post-inflammatory hyperpigmentation (skin discoloration), scarring, permanent hair loss from scalp involvement, nail damage, and a small increased risk of oral squamous cell carcinoma in chronic oral lichen planus. Genital involvement can lead to scarring and anatomical changes.

While lichen planus itself is not dangerous and cutaneous forms typically resolve without long-term consequences, certain complications can occur, particularly with chronic or inadequately treated disease. Understanding these potential complications highlights the importance of proper management and regular follow-up.

Skin Complications

Post-inflammatory hyperpigmentation is the most common complication of cutaneous lichen planus. After the active lesions resolve, brownish or grayish discoloration often remains in the affected areas. This is more prominent in individuals with darker skin tones and can persist for months to years, though it typically fades gradually over time. Sun protection can help prevent worsening of hyperpigmentation.

Hypertrophic lichen planus, typically occurring on the lower legs, can become very thick and persistent, sometimes lasting for years. These thickened plaques may be more resistant to treatment and can occasionally lead to scarring.

Oral Complications

Erosive oral lichen planus can cause significant pain and difficulty eating, potentially leading to nutritional deficiencies and weight loss in severe cases. The most important complication to be aware of is the small but established risk of malignant transformation - chronic oral lichen planus has approximately a 1-2% risk of developing into oral squamous cell carcinoma over many years. This is why regular monitoring by a healthcare provider is recommended for patients with oral lichen planus.

Scalp and Nail Complications

Lichen planopilaris can cause permanent, scarring hair loss (cicatricial alopecia) as the inflammatory process destroys hair follicles. Early treatment is crucial to preserve as much hair as possible, as destroyed follicles cannot regrow hair.

Nail lichen planus can lead to permanent nail damage, including scarring of the nail matrix that results in nail dystrophy (abnormal nail growth), splitting, or complete nail loss.

Genital Complications

Genital lichen planus, particularly the erosive form, can lead to scarring that causes anatomical changes. In women, this can result in vaginal narrowing or fusion of the labia. In men, scarring of the foreskin or urethral involvement can occur. These complications can significantly impact sexual function and quality of life.

What Is the Outlook for Lichen Planus?

The outlook for lichen planus is generally good. Cutaneous lichen planus typically resolves within 1-2 years, though it may recur in some patients. Oral lichen planus tends to be more chronic and may persist for many years, but can be well-controlled with treatment. Early treatment of scalp and nail involvement is important to prevent permanent damage.

The prognosis for lichen planus depends on the type and location of involvement. Understanding what to expect can help you plan for long-term management and set realistic expectations for treatment outcomes.

Cutaneous Lichen Planus

Most cases of cutaneous (skin) lichen planus follow a self-limiting course, meaning they resolve on their own over time. Approximately two-thirds of patients see their skin lesions clear within 1-2 years. However, about 15-20% of patients may experience recurrence after initial clearing. While the active lesions resolve, post-inflammatory hyperpigmentation may persist for months to years before fading.

Oral Lichen Planus

Oral lichen planus tends to be more chronic than the cutaneous form and may persist for many years or even indefinitely. While it can be well-controlled with treatment, complete permanent remission is less common. The reticular (white lacy) form is often asymptomatic and may not require treatment, while the erosive form typically requires ongoing management. Regular follow-up is important due to the small risk of malignant transformation.

Other Forms

Genital lichen planus can also be chronic and may require long-term management. With appropriate treatment, symptoms can usually be well-controlled, and complications such as scarring can be minimized.

For lichen planopilaris (scalp), the outlook depends heavily on how early treatment is initiated. While the inflammation can usually be controlled, any hair loss that has already occurred is permanent. This underscores the importance of seeking early evaluation for scalp symptoms.

Nail lichen planus can be challenging to treat, and outcomes are variable. Some patients respond well to treatment, while others may have permanent nail damage despite therapy.