Article by Dr Manasa S, B.A.M.S

Lichen planus is a chronic inflammatory condition that affects the skin, nails, oral mucosa, scalp, arms, legs, and genital regions. Known as lichenoid dermatitis among healthcare professionals, this condition manifests as purple, itchy, flat elevated lesions on the skin, often developing over several weeks. These lesions can be particularly bothersome due to their appearance and the intense itching they cause.

In the mouth and genital regions, lichen planus often presents as lacy white patches, which can sometimes be accompanied by painful sores. Although it can affect anyone, the condition is most commonly seen in middle-aged adults and is known for its unpredictable course, where symptoms may resolve within months but have the potential to recur.

Early recognition and appropriate management can help alleviate symptoms and prevent complications, making a comprehensive knowledge of this condition beneficial for effective treatment and patient care.

Causes of lichen planus

The cause of lichen planus is still not completely understood, but the immunity component is not ruled out. It is most commonly understood as related to the immune system attacking cells of the skin or mucous membrane. Some research says that lichen planus is not an autoimmune condition, but the responses resemble immunity disorders. It is an idiopathic condition where the causes of the diseases are unknown.

In a healthy individual, T cells of the immune system perform the function of protecting the body from infections. However, in people suffering from lichen planus, their immune system’s T cells attack a protein in their skin and mucous membrane. It is not clear what makes the T cells attack the protein.

The main causes can be outlined as under:

–        Allergens
–        Viral infections
–        Stress
–        Genetics
–        In few circumstances, lichen planus occurs along with the autoimmune disorders

Signs and Symptoms of lichen planus

The general symptoms of lichen planus depend on which part of the body it affects. Symptoms are as below –

–        Purple, shiny, raised bumps usually on the inner forearms, wrists or ankles
–        Lacy white patches on the tongue or inside of cheeks
–        Moderate to severe itching
–        Sores in the mouth and genitals are often painful
–        Hair loss, though rare
–        Dark lines from the tip of the nail to the base
–        Nail scarring or loss

Detailed description of symptoms according to body parts it affects

Skin: The most common symptoms are red or purple raised skin lesions often referred to as bumps. These bumps are firm and may itch a lot or little. They may be few in number to a lot of them and may be associated with white lines or scales. They can occur anywhere, but are most common on wrists, arms, and ankles. These bumps sometimes appear in the places on the skin where the skin has already been burned or scratched.

Mouth: Lichen planus in the oral cavity appears like a lacy patch of white tiny dots. These patches may be found on the tongue also. In mild cases, they may not cause any symptoms at all or few symptoms, but in severe conditions, they cause redness and soreness.

Nails: Lichen planus may appear on a few, or all of the fingernails and toenails. Thinning, ridge forming, splitting and nail loss are the signs of this condition.

Scalp: Tiny bumps, redness, and irritation can be seen on the scalp. In certain cases, hair thinning and hair loss is also observed.

Genitals: Redness and soreness are the main signs of genital lichen planus.

Pattern of presentation noted commonly in lichen planus patient history

Lesions initially develop on the flexural surfaces of the limbs, with a generalized eruption pattern developing after a week or more and extensive spreading within 2 to 6 months.

Itching of varying severity, depending on the type of lesion and the extent of involvement.

Oral lichen planus may be asymptomatic, burning, redness or even painful.

The lesions that occur on the skin surfaces typically resolve within 6 months. This is seen in 50% and 18 months in around 18% of cases.

Chronic lesions are more likely oral lichen planus or with large annular hypertrophic lesions and mucous membrane involvement.

Certain variations of clinical presentation

–        Atrophic lichen planus
–        Hypertrophic lichen planus
–        Ulcerative or erosive lichen planus
–        Annular lichen planus
–        Linear lichen planus
–        Follicular lichen planus
–        Vesicular lichen planus
–        Bullous lichen planus
–        Actinic lichen planus
–        Lichen planus pemphigoides
–        Lichen planus pigmentosus

Certain triggering factors have been identified which are as mentioned below

–        Hepatitis C infection
–        An allergic reaction to the metal in dental fillings
–        Recent research which is published in the year 2021 says that certain factors point to genetic susceptibility. Therefore, now it is understood that lichen planus can run in the families.
–        Painkillers and certain other medications
–        Vaccines
–        Particular chemicals, metals or pigments
–        Certain medicines used to treat arthritis, heart disease or high blood pressure.

Risk factors

Anyone can get affected with lichen planus, but it most often affects middle aged adults. Lichen planus in the mouth affects women more than men. Some studies suggest that women might get lichen planus twice as often as men, and they are more likely to develop it in their 60s. Men are more likely to develop in their 40s.

Complications

Lichen planus can be difficult to treat if it affects the vulva, vagina causing scarring associated with severe pain. Sores on the genitals are extremely painful and make sex painful.

Sores in the oral mucosa make it difficult to eat food. Oral lichen planus may increase the risk of oral cancer.

Lichen planus if affects the ear, it may lead to hearing loss.

Lichen planus of skin and nails even after the treatment might stay as slightly darker patches.

Osteoporosis, infection, adrenal insufficiency, bone marrow suppression, renal damage, hyperlipidemia, and growth restriction in children may occur due to adverse effects of medication.

Residual hyperpigmentation after the inflammation may be a common sign after lichen planus has subsided.

Alopecia associated with lichen planus is most of the times permanent

Epidemiology

There is no significant geographical variation in frequency noted for lichen planus.

United states: It is reported in approximately 1% of all new patients seen at healthcare clinics. Some parts of the USA reported to have observed higher prevalence in December and January.

Race: No racial predisposition has been reported for lichen planus.

Sex: No significant difference in incidence for lichen planus are noted between male and female patients, but women are more likely to suffer from lichen planus.

Age: More than two third of lichen planus patients are aged between 30-60 years; however, it can occur at any age.

Incidence of lichen planus

Approximately 0.22% to 1 % of the adult population is affected. The incidence of oral lichen planus worldwide is 1% to 4 %.

Common diagnostic criteria of lichen planus

It is typically diagnosed after the assessment of symptoms and physical examination. Lichen planus has some special characters which are known by the term “six Ps” that help to diagnose the condition are:

–        P1 – Pruritic [The itchy skin lesions]
–        P2 – Purple lesions [bumps]
–        P3 – Plaques [raised, discolored, patches]
–        P4 – Polygonal [sharp angled rash]
–        P5 – Planar [ top is flat]
–        P6 – Papules

Further diagnosis is done with the help of the following investigations –

–        Allergy test: An allergy test done can determine if allergy is the reason for flaring up of the lichen planus
–        Biopsy: It is done to understand the extent of the skin lesion
–        Hepatitis C test: As sometimes lichen planus is associated with hepatitis C virus

Can lichen planus be prevented?

No, as the causation is not clearly understood, there isn’t any way to prevent lichen planus.

Is lichen planus contagious?

Lichen planus is not contagious. Lichen planus cannot spread to another person through unprotected sex or skin to skin contact.

Treatment and Management

Antihistamines: These are given to relieve itching of varying degrees

Topical corticosteroid cream: Cream or ointment to reduce swelling and redness

Oral corticosteroids: Pills or injections of corticosteroids help when lichen planus lasts for long time or when patient has many bumps or painful sores

PUVA therapy: A type of light treatment which uses ultraviolet light, usually ultraviolet B from special lamps, may help to clear the skin lesions

Retinoic acid: This is applied to the skin or given as a pill to help the skin lesions

Immunosuppressants:  Medications that lower the immune system such as oral corticosteroids, mycophenolate mofetil, azathioprine or cyclosporine can be helpful

How to live with the condition

Practice of good oral hygiene: Regular brushing and flossing the teeth, and getting checked and cleaned by professional dentist at least twice a year

Replace dental fillings:  Some people might have allergies to the mixtures of different mixtures of metals used in tooth fillings. These allergic reactions might look like lichen planus. Replacing the dental fillings with hypo allergic combination might improve the redness and soreness in oral mucosa

Avoid skin injuries

Use cool compress during extreme itching and painful phases instead of scratching, as scratching further exacerbates the condition

Stress in the life should be managed as stress acts as triggering factor

To take control of symptoms of oral lichen planus, stopping smoking, avoiding alcohol, maintaining good oral hygiene and avoiding all foods that might irritate the oral mucosa are mandatory.

Emotional or mental stress that worsens lichen planus symptoms

–        Anxiety
–        Depression
–        Difficulty relaxing
–        Use of alcohol, tobacco or drugs to relieve stress
–        Low self esteem
–        Feeling overwhelmed
–        Difficulty in concentrating
–        Mood swings, irritability or a short temper

Prognosis of Lichen Planus

The prognosis for lichen planus is generally favorable, despite the moderate to severe itching that often accompanies the condition. Most cases resolve within 18 months. However, it is important to note that some lesions may recur over time.

Skin lichen planus does not increase the risk of skin cancer. However, ulcerative lesions in the mouth, particularly in men, carry a low but notable risk of transformation into cancer. Additionally, vulvar lichen planus has been associated with an increased risk of developing squamous cell carcinoma. Overall, while lichen planus can cause significant discomfort and potential complications, the long-term outlook is positive for most patients with proper management and monitoring.

Study – Lichen planus is a disease of adults (20-40 years) according to western data, but in the Indian population it is common in the pediatric age group (less than 18 years age group). The disease is relatively more common in females than in males. Classically it has a strong association of involvement of the lower limbs in the younger age group. Involvement of the upper limb is more common in female patients.

Study – ‘A study of depression and quality of life in patients of lichen planus’ – showed a strong association between depression and impairment in quality of life in both genders suffering from lichen planus. This study helps in early identification of psychological problems in lichen planus patients and in planning their future course of management, hence reducing the lack of productivity and improving the prognosis and quality of life.

Epidemiological studies – In comparison to the normal population, there is a higher prevalence of hepatitis C virus infection in patients suffering with lichen population.

Lichen Planus: Ayurveda Understanding

From dosha perspective, being an inflammatory condition, Lichen Planus is definitely caused by pitta aggravation. It is also triggered by pitta aggravating etiological factors. Itching in Lichen planus is caused by aggravated kapha, vata or both kapha and vata.

Lichen planus is manifested on the skin and is primarily a skin condition / disease. Therefore, it can be included under ‘Kushta’. The symptoms of Alasaka, Udumbara / Audumbara, Mandala, Pundarika and Pama Kushtas resemble the clinical picture of Lichen Planus.

The explanation of Lichen Planus also includes it under the category of raktagata or pittaja kushta.

The etiological factors mentioned in the context of Kushta, vitiation of rasavaha and mamsavaha srotas and tridosha imbalance can be considered in the causation of lichen planus.

Nidana Parivarjana i.e. keeping away the causative factors of kushta and those which contaminate channels of transportation of rasa, rakta and mamsa are the main principles for preventing the progression of the disease, preventing it in the susceptible people and to prevent the recurrence of the disease and its symptoms.

When manifested, lichen planus shall be treated on the lines of treating kushta and contamination of the mentioned channels. Virechana and Vamana are the most important Panchakarma therapies which are highly effective in the treatment and management of lichen planus.

As and when required, external therapies like lepa and parisheka as explained in the context of kushta and vatarakta – for relief of symptoms like itching and inflammation, Rasayana – for preventing the recurrence and complete recovery, Sattvavajaya Chikitsa – psychotherapy to manage stress, which is an important trigger, Daiva Vyapashraya Chikitsa – divine and belief therapies considering lichen planus as idiopathic condition, treatment principles of krimi – microorganisms, and visha chikitsa should be considered.

Shodhana and Rasayana therapies should be planned and administered for ‘parents to be’ so that they get healthy babies into the world, especially in presence of family history of lichen planus on one or both sides of the families.

Related Reading – ‘Lichen Planus – Ayurveda Understanding’