LICHEN PLANUS

Dermatology Presentations January 2012

CLINICAL SCENARIO

A 40 year old woman presented with intensely pruritic lesions on her wrists

ADDITIONAL HISTORY
Onset: Usually insidious. Initially develops over 1+ wks. Spread is maximum within 2-16 wks. Site: Other areas affected? Mucous membranes especially. NB Oral lesions and anogenital lesions. (Dyspareunia?) PMHx: Similar condition in the past? Any autoimmune diseases (weak link)? Hx of Hep C, chronic active hepatitis and primary biliary cirrhosis? Contact hx Drug hx: Lichenoid drug reaction Family history: Possibly HLA-B7 link

EXAMINATION

The wrist lesions remember the 4PS

Pruritic Polygonal Purple(violaceous) Papules Scaly (sometimes)

Flexor areas slight predilections

Mouth gums, buccal mucosa and tongue. Common. Usually, a reticular appearance - white lacy streaks on purple background (known as

Wickhams striae). Occasionally erosive, ulcerative or bullous.

Nails involved in 10% cases. Usually thinning with ridging and grooving of nails.

Scalp can cause cicatricial alopecia. Hair will not regrow.

Genitourinary papules on glans penis. Vulval involvement reticular to erosive. Urethral stenosis can occur.

INVESTIGATIONS
Usually, not necessary. Clinical diagnosis. Occasionally, skin biospy performed for histology. (Keratinocyte degeneration, globular deposits of IgM/IgA and

complement in lower dermis.)

May consider Hep. C screen depending on the hx.

DIAGNOSIS: CAUSES AND DIFFERENTIALS

Lichen planus is a cell-mediated response of unknown immunological origin. Histology shows bands of lymphocytes attacking basal keratinocytes. Differenial diagnosis: Pityriasis Rosea Psoriasis (plaque or guttate) Tinea corpis Lichen simplex chronicus Graft versus host disease Syphilis

TREATMENT AND LIKELY COURSE

Patience no quick cure Generally antihistamines and emollients. Steroids topical, paste for oral lesions, or oral for severe disease Immunosuppressants only by a specialist, only for severe disease PUVA as above. Good outlook rule of thumb. W/o tx, 55% clear w/n 6-9 months. But can persist >2 yrs usually in those with GU or oral lesions If oral or vulval involvement slighlty raised chance of cancer.

REFERENCES
E-medicine: http://emedicine.medscape.com/article/1123213overview Patient.co.uk: http://www.patient.co.uk/health/Lichen-Planus.htm