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Lichen planus II
IMAGING: N/A
DIAGNOSTIC PROCEDURES: Skin biopsy
TREATMENT APPROPRIATE HEALTH CARE: Outpatient
GENERAL MEASURES: • Goal is to relieve itching with topical and systemic antipruritics
• Psoralens and ultraviolet A (PUVA) photochemotherapy may be helpful for generalized or resistant cases
• Behavior modification for stress reduction may prevent recurrence
SURGICAL MEASURES: N/A
ACTIVITY: Fully active
DIET: No special diet
PATIENT EDUCATION: Help with stress reduction if appropriate
MEDICATIONS DRUG(S) OF CHOICE: • Skin
• Topical steroids (e.g., 0.1% triamcinolone acetonide) with occlusion
• Intralesional corticosteroids, e.g., triamcinolone (Kenalog) 5-10 mg/mL) for hypertrophic lesions
• Antihistamine (e.g., hydroxyzine, dosage - 25 mg q6h) if needed for itching
• Mucous membranes
• Topical oral retinoids, e.g., 0.05% tretinoin (retinoic acid) in Orabase or topical oral corticosteroids (0.1% triamcinolone (Kenalog in Orabase) bid
• Intralesional corticosteroids for erosive, painful lichen planus, e.g., 0.5-1.0 mL methylprednisolone (Depo-Medrol) 40 mg/mL
• Oral retinoids - isotretinoin (Accutane) or etretinate (Tegison)
Contraindications: Patients with history of hypersensitivity to corticosteroids or retinoids
Precautions:
• Systemic absorption of steroids may result in hypothalamic-pituitary-adrenal axis suppression, Cushing's syndrome, hyperglycemia, and glucosuria
• Increased risk with high potency - i.e., use over large surface area, prolonged use, occlusive dressings
• These medications are Category C teratogens. Avoid in pregnancy.
• Children may absorb a proportionally larger amount of topical steroid due to larger skin surface to weight ratio
Significant possible interactions: See manufacturer's profile of each drug
ALTERNATIVE DRUGS: • Oral prednisone - rarely used and only for a short course (e.g., prednisone 20 mg bid x 2-4 weeks)
• Cyclosporine may be used in severe cases, but cost and potential toxicity limits its use. Topical use for severe oral involvement refractory to other treatments.
FOLLOW UP PATIENT MONITORING: Serial skin exams
PREVENTION/AVOIDANCE: Reduce stress
POSSIBLE COMPLICATIONS: • Alopecia
• Nail destruction
• Squamous cell carcinoma of the mouth
EXPECTED COURSE AND PROGNOSIS: • Spontaneous resolution in weeks is possible, but disease may persist for years - especially in the mouth and on shins
• There is a tendency toward relapse, especially with emotional stress
• Recurrence 12-20% especially in those with generalized involvement
MISCELLANEOUS ASSOCIATED CONDITIONS: • Hepatitis C
• Lichen nitidus
• Bullous pemphigoid
• Alopecia
• Myasthenia gravis
• Lupus erythematosus
• Biliary cirrhosis
• Vitiligo
• Ulcerative colitis
• Graft-versus-host reaction
• Morphea and lichen sclerosus et atrophicus
AGE-RELATED FACTORS:
Pediatric: N/A
Geriatric: N/A
Others: N/A
PREGNANCY: Avoid corticosteroids, retinoids
SYNONYMS: N/A
ICD-9-CM: 697.0 Lichen planus
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Bronchiolitis
Common cold
Epiglottitis
Tracheitis, bacterial
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