Lichen Planus: Symptoms, Types, Causes and Treatment

Lichen planus is a chronic, inflammatory condition that can affect the skin, mucous membranes, nails, and even internal organs such as the esophagus. While it’s not contagious, lichen planus can significantly impact quality of life due to its persistent symptoms, visible lesions, and association with discomfort and psychological distress. Understanding its symptoms, types, causes, and treatment options is essential for patients, caregivers, and healthcare professionals. This article provides a comprehensive overview based on the latest research.

Symptoms of Lichen Planus

Lichen planus presents with a variety of symptoms, which can differ based on the site and variant of the disease. Recognizing these symptoms is crucial for timely diagnosis and management, as early treatment can help alleviate discomfort and prevent complications.

Symptom	Description	Frequency/Location	Source(s)
Itching	Intense, persistent itch (pruritus)	Most common, especially on limbs	1 16
Papules	Flat-topped, polygonal, purple-colored bumps	Flexor wrists, forearms, legs	2 16
Wickham Striae	Lacy, white lines on lesions or mucosa	Skin, oral, and genital mucosa	13 16
Mucosal Lesions	Erosions, white striations, pain	Oral cavity, genitalia, esophagus	3 5 12
Nail Changes	Thinning, ridging, splitting, destruction	Fingernails and toenails	1 2 16
Psychological	Depression, anxiety	Associated, not direct symptoms	4

Table 1: Key Symptoms

The Classic Presentation

The typical skin lesions of lichen planus are described as the "six P's": planar (flat-topped), purple, polygonal, pruritic (itchy), papules, and plaques. These are most often found on the flexor surfaces of the wrists, forearms, and legs. The papules are often covered by a fine network of white lines known as Wickham striae, which is a hallmark of the disease 2 16.

Mucosal Involvement

Mucosal lichen planus can be particularly distressing. Oral lichen planus (OLP) often appears as white, lacy patches, red swollen tissues, or open sores inside the mouth, causing discomfort or pain. Genital and esophageal involvement can lead to erosive, painful lesions and, if chronic, may result in scarring and even narrowing (stenosis) of affected areas 3 5 12.

Other Sites and Associated Symptoms

• Nails: Up to 15% of patients may exhibit nail changes, which can include thinning, ridging, splitting, or even loss of the nail 1 2 16.
• Psychosocial Impact: Lichen planus can have a significant impact on mental health, with a higher prevalence of depression and anxiety among sufferers. This highlights the need for a holistic approach to management 4.

Less Common Symptoms

• Scalp Involvement: Leads to patchy hair loss (lichen planopilaris) 2.
• Esophageal Symptoms: Such as difficulty swallowing (dysphagia), especially in women 5.

Types of Lichen Planus

Lichen planus is not a single disease but a group of related disorders with diverse presentations. Understanding its types is essential for accurate diagnosis and tailored treatment.

Type	Main Features	Common Sites	Source(s)
Classic Cutaneous	Pruritic, flat-topped, violaceous papules	Limbs, wrists, trunk	1 2 16
Oral	White striae, erosions, plaques	Buccal mucosa, tongue, gums	3 6 10 12
Hypertrophic	Thickened, wart-like plaques	Shins, vulva	1 2 7
Annular/Linear	Ring-shaped or linearly arranged lesions	Trunk, extremities	2
Erosive	Painful ulcers/erosions	Oral, vulvar, penile, esophagus	2 3 5 7
Lichen Planopilaris	Scarring alopecia	Scalp	2
Nail	Thinning, ridging, destruction	Nails	1 2 16
Pigmentosus	Dark macules/patches	Face, neck, flexures	8
Esophageal	Dysphagia, mucosal denudation	Esophagus	5
Vulvovaginal	Erosive, classic, hypertrophic lesions	Vulva, vagina	7

Table 2: Main Types of Lichen Planus

Classic Cutaneous Lichen Planus

The most common form, presenting as itchy, purple papules on the skin. Lesions are often symmetrical and may persist for months to years 1 2 16.

Oral Lichen Planus (OLP)

A chronic inflammatory disease of the oral mucosa, OLP can manifest as white reticular patterns, erosions, plaques, or blisters. It may be asymptomatic or cause significant pain and increase the risk of oral cancer in a small percentage of patients 3 10 11 12.

Hypertrophic and Annular Forms

• Hypertrophic: Characterized by thick, warty plaques, especially on the shins or vulva. These lesions are more resistant to treatment and may persist longer 1 2 7.
• Annular/Linear: Less common, with ring-shaped or linear lesions.

Lichen Planopilaris

Affects the scalp, leading to inflammation and scarring hair loss—often permanent if untreated 2.

Nail, Pigmentosus, and Other Variants

• Nail Lichen Planus: May cause thinning, ridging, and eventual nail loss 1 2 16.
• Lichen Planus Pigmentosus: Presents as dark, slate-gray macules, typically on sun-exposed or flexural skin, more common in individuals with darker skin 8.
• Esophageal Lichen Planus: Rare but serious, can cause difficulty swallowing and increase the risk of esophageal cancer 5.
• Vulvovaginal Lichen Planus: May be erosive, classic, or hypertrophic, affecting the vulva and vagina with potential for scarring and functional impairment 7.

Causes of Lichen Planus

While the exact cause of lichen planus remains uncertain, research has identified a combination of immune, genetic, and environmental factors that contribute to its development.

Cause/Trigger	Mechanism or Association	Notes/Examples	Source(s)
Immune Dysregulation	T-cell mediated attack on skin/mucosa	Chronic inflammation	3 10 16
Drugs/Medications	Lichenoid drug reactions	β-blockers, methyldopa, NSAIDs	13 14
Viruses	Possible association with hepatitis C	Especially in pigmentosus variant	8
Allergens	Dental metals (e.g., copper), flavorings	Contact lichenoid reactions	6 13
Genetic Factors	Susceptibility in certain individuals	Family history sometimes noted	8
Unknown Factors	Idiopathic in most cases	No clear trigger identified	2 16

Table 3: Recognized and Suspected Causes

Immune-Mediated Pathogenesis

Lichen planus is widely believed to be a T-cell mediated autoimmune disease. The immune system mistakenly targets basal keratinocytes in the skin and mucous membranes, leading to chronic inflammation and characteristic lesions 3 10 16. Both antigen-specific (directed at certain proteins or altered self-antigens) and non-specific mechanisms (mast cell degranulation, matrix metalloproteinase activation) are involved 10.

Drug-Induced and Contact Reactions

Several medications can induce lichenoid reactions that are clinically and histologically similar to idiopathic lichen planus. Notable culprits include β-blockers, methyldopa, penicillamine, quinidine, quinine, and NSAIDs. Distinguishing drug-induced from idiopathic lichen planus can be challenging but is crucial for management, as withdrawal of the offending drug may lead to resolution 13 14.

Contact with certain dental metals (such as copper) or flavoring agents (like cinnamates) can also trigger lichenoid lesions in the oral cavity 6 13.

Viral and Environmental Factors

There is evidence of an association between hepatitis C virus and certain forms of lichen planus, especially lichen planus pigmentosus 8. Sun exposure and other environmental triggers may also play a role in susceptible individuals.

Genetic Susceptibility

While not fully understood, some individuals may have a genetic predisposition to developing lichen planus, possibly due to variations in immune regulation 8.

Treatment of Lichen Planus

The goal of lichen planus treatment is to relieve symptoms, promote healing of lesions, reduce the risk of complications (including cancer in mucosal forms), and improve quality of life. Management varies depending on the form, severity, and location of the disease.

Therapy Type	Main Options/Examples	Indication/Notes	Source(s)
Topical Corticosteroids	Clobetasol, betamethasone valerate	First-line for most cases	3 15 16 18
Calcineurin Inhibitors	Tacrolimus, pimecrolimus	Alternative, mucosal/genital	16 18
Systemic Corticosteroids	Prednisolone, oral steroids	Severe or widespread cases	3 15 16
Retinoids	Acitretin	Resistant cutaneous cases	15 16 18
Immunosuppressants	Methotrexate, cyclosporine, hydroxychloroquine	Severe/refractory cases	15 16 18
Phototherapy	NBUVB, PUVA, PUVASOL	Generalized skin disease	15 18
Photodynamic Therapy	PDT	Oral lichen planus	17 19
Symptom Management	Antihistamines, analgesics	Itch, pain relief	3 16
Other Therapies	Sulfasalazine, griseofulvin, endoscopic dilation (ELP)	Select cases	5 15 18

Table 4: Main Treatment Options

First-Line Therapies

Topical corticosteroids are the mainstay of treatment for most forms of lichen planus. They effectively reduce inflammation and promote lesion healing in skin, oral, and genital forms. For mucosal or genital involvement, high-potency topical corticosteroids or topical calcineurin inhibitors (like tacrolimus) are preferred 3 16 18.

Systemic and Advanced Therapies

When topical treatments are insufficient, systemic corticosteroids or immunosuppressants may be required. Oral retinoids (such as acitretin) and immunomodulatory drugs (methotrexate, cyclosporine, hydroxychloroquine) are used in severe or refractory cases, though they carry a higher risk of side effects 15 16 18.

Phototherapy and Photodynamic Therapy

• Phototherapy: Narrow-band UVB (NBUVB) and psoralen plus UVA (PUVA) are effective for generalized cutaneous disease 15 18.
• Photodynamic Therapy (PDT): Especially promising for oral lichen planus, PDT is safe, non-invasive, and has demonstrated significant improvement in clinical studies 17 19.

Other Considerations

• Esophageal Involvement: May require topical steroids or immunosuppressants; severe cases with stenosis may need endoscopic dilation 5.
• Psychological Support: Screening for and addressing depression or anxiety is important 4.
• Cancer Surveillance: Long-term follow-up is necessary for patients with oral, esophageal, or genital lichen planus due to a small but significant risk of malignant transformation 3 5 11.

Treatment Challenges

Spontaneous remission can occur, but recurrences are common. Mucosal and hypertrophic forms may be more resistant to therapy and require long-term management 1 2 16 18.

Conclusion

Lichen planus is a complex, chronic inflammatory disease with diverse symptoms, types, causes, and treatment options. Awareness and early recognition are key to effective management and improving patient quality of life.

Key Takeaways:

• Lichen planus presents with itchy, purple papules, mucosal lesions, nail changes, and can impact psychological health 1 2 3 4.
• There are multiple types, including classic cutaneous, oral, hypertrophic, pigmentosus, esophageal, and more, each with unique features and challenges 1 2 3 5 7 8.
• The disease is primarily immune-mediated, with drugs, allergens, viruses, and genetic factors playing contributory roles 3 8 10 13 14 16.
• Treatment focuses on topical corticosteroids as first-line therapy, with systemic agents, phototherapy, and emerging options like PDT for more severe or resistant cases 3 15 16 17 18 19.
• Regular follow-up is crucial for monitoring complications and addressing psychosocial impacts 3 4 5 11 16.

Understanding lichen planus empowers patients and clinicians to work together for optimal outcomes, adapting management strategies to each individual's needs and disease course.