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What is lichen plan? Causes, Symptoms and Treatment

The lichen planus is a chronic dermatosis that occurs preferentially in middle – aged adults  : it occurs in 2/3 of the cases between 30 and 60 years and it is rare at the extreme ages of the life. It affects women as much as men. It concerns about 1% of the population.

It presents itself, in its typical form, as itchy , purplish, scaly skin elevations , located on the wrists and ankles in particular. It can also affect the oral and genital mucosa. A particular form concerns the scalp (lichen planar pilaris).

Does the lichen plan have a cause?

The cause of lichen planus is not known ; it is considered to be an autoimmune process but lacks evidence.

Other diseases are associated with lichen planus: thymoma, Castelman’s disease, Biermer’s disease, Addison’s disease, alopecia areata, diabetes, ulcerative colitis …

The association with chronic liver disease (primary biliary cirrhosis, hepatitis C …) seems more common in erosive mucosal lesions of lichen planus.

 

Symptoms of lichen plan

The lichen planus is a dermatosis that can affect the skin, mucous membranes and integuments (hair, nails)

1 / Lichen cutaneous plane

The lichen planus is characterized by the appearance of papules (skin elevations) of pinkish then purple color, traversed on the surface by fine characteristic gray streaks called streaks of Wickham. They can be observed on all parts of the body, but they are found preferentially on the anterior sides of the wrists and ankles .

Of linear lesions can appear along scratch marks or scars , realizing the Koebner phenomenon.

The lichen planus papules are almost constantly itching .

Then, the purple papules collapse and leave room for residual pigmentation whose color varies from light brown to blue, or even black. We talk about lichen pigmentary plane

2 / Lichen mucosal plane

It is estimated that about half of the patients with lichen planus skin have an associated mucosal involvement . Lichen planus may also affect mucous membranes without skin involvement in ¼ of cases. The women are more often affected the mucosal level than men. The oral mucosa is most often affected, but all the mucous membranes can be reached: the genital area, the anus, the larynx, the esophagus …

2.A / Lichen oral plane

The oral lichen includes the following clinical forms: reticulate, erosive and atrophic. Preferred locations are the mucous membrane or tongue.

2.Aa / Lichen reticulated oral plane

The reticulate lesions are typically without symptoms (without burning, itching …) and bilaterally on the two inner faces of the cheeks . They create a whitish network  of  ” fern leaf “.

2.Ab / Lichen erosive oral plane

The erosive lichen planus is characterized by eroded and painful mucosal areas with clear boundaries, covered with pseudomembranes, on a red background , associated or not with a reticulated lichen network. It sits preferentially on the inside of the cheeks, the tongue and the gums .

2.Ac/ Lichen atrophic plan

The atrophic forms (the mucosa is thinner on the lichen areas) are more readily observed on the gums that are irritated when brushing the teeth and the back of the tongue, causing depapillation, making the tongue more sensitive to food spicy .

2.B / Lichen genital plane

Genital mucosal involvement by lichen planus is much rarer than oral involvement . It affects both men and women and the affected areas are the inner side of the labia majora and labia minora in women, the glans in men . The genital lesions are comparable to those of oral lichen (reticulate, erosive or atrophic forms). In women, a vulvo-vagino-gingival syndrome is described , associating:

 

  • erosive vulvitis, and sometimes a reticulated network around the lesions;
  • erosive vaginitis;
  • Erosive gingivitis in layers, associated or not with other oral lesions of lichen.
  1. Phaniferous attack (hair, nails, hair)

3.A / Lichen hair plan: lichen follicular plan

Bruising may occur in the course of a typical lichen cutaneous surge, in the form of small, acuminate, hair-centered spikes, called spinulosic lichen .

3.B / Lichen hair plan: lichen hair plan

On the scalp, lichen planus is characterized by areas of alopecia (areas without hair) cicatricial appearance (the scalp is whitish and atrophic).

Lassueur-Graham-Little syndrome is associated with scalp involvement, spinulosic lichen, and axillary and pubic hair loss.

A particular form of hair lichen has been individualized in postmenopausal women over 60 years of age: postmenopausal fibrosing frontal alopecia , characterized by a frontotemporal cicatricial alopecia in the crown at the edge of the scalp and a depilation of the eyebrows.

3.C / Lichen nail plan: lichen nail plan

The nails are affected most often during severe and diffuse plane lichens. A thinning of the nail tablet is usually observed, preferably affecting the big toes. The lichen plane nail can evolve to destructive and irreversible damage to the type of pterygion (the nail is destroyed and replaced by skin).

Medical treatment of lichen plan

1 / Lichen cutaneous plane

The goal of skin treatment is to shorten the healing time and reduce itching .

The first-line treatment prescribed by the doctor most often associates a local corticosteroid treatment ( strong or very strong class of corticosteroids ) with a moisturizer treatment , or even antihistaminesin case of strong itching.

If there is no improvement, the doctor can prescribe oral corticosteroids, or even acitretin(Soriatane), which is a vitamin A derivative.

The phototherapy (UVB or PUVA, issued cabin doctor’s office) may also be offered treatment in cutaneous involvement

 

2 / Mucous damage

2.A / Lichen oral plane

2.Aa / Lichen reticulated oral plane

Since the cross-linked lesions are asymptomatic and therefore not very troublesome for the patient, they are generally not treated.

2.Ab / Lichen erosive and atrophic oral plane

It is generally recommended to avoid any oral irritant (tobacco, alcohol …)

The doctor often prescribes local corticosteroids (Buccobet) or a tretinoin cream (Ketrel, Locacid, Effederm…).

In the absence of improvement or in the forms immediately severe, the doctor can prescribe oral corticosteroids .

2.B / Lichen genital plane

The doctor most often uses very strong class topical corticosteroids which generally give good results.

  1. Phaniferous attack (hair, nails, hair)

3.A / Lichen hair plan: lichen follicular plan

The doctor uses strong class dermocorticoids .

3.B / Lichen hair plan: lichen hair plan

The doctor uses strong class topical corticosteroids alone or combined with corticosteroid injections into the scalp . In case of resistance to treatment, he then uses oral corticosteroids, or even acitretin (Soriatane), which is a vitamin A derivative.

3.C / Lichen nail plan: lichen nail plan

The nails can disappear under the effect of lichen plan, the doctor prescribes the most often oral corticoids, sometimes associated with injections of corticosteroids in the matrix of the nail (the base of the nail).

 

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