Lichen planus – causes, symptoms, photos, treatment

Lichen planus is a chronic and recurrent disease of the skin, mucous membranes and nails, characterized by clinically and histologically typical papular lesions and pruritus.

Red lichen planus – definition

Lichen planus as a separate disease entity was first described by Erasmus Wilson in 1869.

Epid.: Chronic dermatosis worldwide. It occurs unequally in different latitudes and is a common skin disease in Africa. The disease of mature age, most often occurs between the ages of 30 and 60, slightly more often in women (55-65% of all patients suffering from lichen planus). The incidence – from 0,2 to 0,5% (European population). It is rare in children, accounting for up to 2% of all lichen cases up to the age of 14.

Prognosis: Chronic, unpredictable course, duration from several months to several years.

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The causes of lichen planus

The etiopathogenesis of lichen planus is not fully understood. The following hypotheses are considered below.

1. Lichen planus – genetic background:

1. family history of lichen planus,
2. in studies of families of people with this dermatosis, a significant increase in the prevalence of the HLA B7 antigen was found.

2. Lichen planus – viral theory:

1. association with HBV infection,
2. frequent coexistence with chronic active hepatitis C,
3. symmetrical arrangement of changes and their occasional spontaneous resolution.

3. Lichen planus – psychogenic background:

1. the occurrence or intensification of lesions in people subjected to severe stress;
2. it has been shown that “the disease rarely affects the carefree” and the presence of certain personality traits such as increased suspicion, distrust, blame, increased anxiety and depressed mood are more common in these individuals.

4. Lichen planus – neurogenic background:

1. neurohistopathological examinations showed changes in the skin innervation. Clinically, eruptions are often linear.

5. Lichen planus – toxic theory:

1. lesions of lichen planus have been reported to occur under the influence of certain chemicals:
2. a.medicines – gold salts, acetylsalicylic acid, antimalarials, neuroleptics, aminoglycoside antibiotics, penicillamines, arsenic, tranquilizers, interferon, less often others,
3. b. color developers (photographers’ disease),
4. c. amalgam fillings – hypersensitivity to materials used for fillings, e.g. mercury.

6. Lichen planus – immune mechanism:

1. the immunological basis of this disease is indicated by its frequent coexistence with autoimmune diseases, such as:
2. a.alopecia areata (alopecia areata),
3. b. bielactwo (vitiligo),
4. c. lupus erythematosus (lupus erythematosus),
5. d. stolen pemphi (pemphigoid),
6. e. organic scleroderma (morphea),
7. f. chronic ulcerative stomatitis,
8. Mr. myasthenia,
9. h. ulcerative enteritis (Crohn’s disease),
10. i. stomach ulcer,
11. j. active hepatitis. The appearance of lichen lumps in patients undergoing allogeneic bone marrow transplantation (“graft versus host” reaction) confirms the involvement of the immune system in the etiopathogenesis of this disease.

Figure 12.1 Red lichen planus. Köbner’s symptom on the torso

Figure 12.2. Red lichen planus. Papular changes on the dorsal surface of the hand

Symptoms of lichen planus

Wedge.: Lesions occur on the skin, mucous membranes and appendages.

1. Changes in the skin

On the skin, they are polygonal, shiny, flat, raised papules, pink, bluish-red or red-brown in color. Within these changes in the side lighting, you can notice an iridescent, delicate mesh, the so-called Wickham mesh. It is the result of an uneven overgrowth of the granular layer of the epidermis.

The lesions may be linear (Köbner symptom), the changes disappear leaving brown discolorations that persist at various times. On the skin, eruptions of lichen planus spread gradually, typically covering the skin of the forearms (mainly the wrist area), the lower limbs (the inner surface of the thighs and lower leg on the extensor side) and the lumbar area. He accompanies the changes itching.

DR: Skin lesions: psoriasis, chronic lichen dandruff, flat warts, neurodermatitis, syphilitic rash.

1. Oral cavity

The lesions occur in about 50% of patients on the oral mucosa. Sometimes they precede the appearance of skin changes or may be the only symptom of this disease. They are linear, tree-like or ring-shaped opacities of the epithelium on the cheek mucosa – along the bite line. Lesions can also be found on the tongue and labial red.

Mucosal lesions: white keratosis, mucosal candidiasis, pemphigus vulgaris, scarring pemphigoid, paraneoplastic pemphigus, aphthae, chronic ulcerative stomatitis (CUS), Queyrat erythroplasia, lichen sclerosus, second period syphilis.

Changes on the scalp – focal form of lupus erythematosus (DLE).

1. Sex organs

The mucous membranes of the genital organs show changes in 20-25% of cases in men, less often in women. In men, they appear in the form of purple lumps, located mainly on the glans and foreskin. In women, changes appear on the labia in the form of white streaky opacities of the epithelium, resembling leukoplakia.

1. Sales

Quite often changes in the rectal mucosa accompanied by severe itching. Sometimes it is the only location of lichen planus. In the area of ​​the scalp, the lesions are peri-follicular lumps, leading to the destruction of the hair follicles and the formation of atrophic scars or permanent alopecia.

1. Other symptoms

Some patients (1-16%) have nail changes, often preceding the appearance of changes on the skin or mucous membranes. They consist in thinning, longitudinal graining, cracking, creasing of the nail plates, and even their disappearance.

Figure 12.3. Red lichen planus. Changes in the cheek mucosa

Figure 12.4. Red lichen planus

Atypical clinical varieties of lichen planus:

1. follicular (Graham-Little syndrome – pseudopelade scalp lesions);
2. outgrown
3. nodular,
4. atrophic,
5. blistering,
6. ulcerative,
7. dye,
8. linear,
9. erythematous
10. annular,
11. exfoliating,
12. actinicus (tropicus) – occurs in countries with a tropical climate, the sun may be the trigger; papular lesions are ring-shaped with greater discoloration in the central part and are limited to the skin of the face.

Hist.: The following are found in the epidermis: hyperplasia of the stratum corneum, rarely with focal parakeratosis, irregular hyperplasia of the granular layer, hypertrophy of the spinous layer, features of aquatic degeneration of the basal layer cells and Civatte bodies in slightly older lesions. Civatte corpuscles are dyskeratotic basal cells that have been keratinized too early, possibly as a result of apoptosis. In the upper part of the dermis, a characteristic inflammatory infiltrate is observed along the dermal-epidermal border, closely adjacent to the epidermis. It is a multicellular infiltrate, mainly composed of lymphocytes and histiocytes, and also includes mast cells and neutrophils.

Treatment of lichen planus

treating lichen planus is difficult and sometimes does not bring the desired results. There is no causal treatment for this dermatosis. It is characterized by a variety of methods used. Limited cutaneous lichen planus should be treated topically; the mucosal, follicular or lichen planus forms, characterized by the involvement of large areas of the skin, require general treatment.

Lichen planus – local treatment:

1. Corticosteroids – steroid therapy of choice for single or small lesions. Hypertrophic and papillary lesions – a good effect is achieved by the use of preparations in occlusive dressings and intralesional injection of corticosteroids, e.g. triamcinolone. Changes in the oral mucosa – topical fluocinolone gel or tramcinolone paste can be used.
2. Vitamin A acid derivatives – are used alternately within the oral mucosa, e.g. 0,05-1,0% tretinoin or 0,1% isotretinoin.
3. Cyclosporin A – Topical use in the treatment of scarring conjunctivitis is questionable.
4. Tacrolimus in the form of a mouthwash solution for erosive lesions on the oral mucosa.
5. Cryotherapy, surgical treatment, CO2 laser – should be considered in the case of long-lasting and resistant erosive lesions on mucous membranes.

Lichen planus – general treatment:

1. Corticosteroids – most effective in acute spread forms of lichen planus, e.g. prednisone, used at a dose of 15-40 mg daily for a few weeks, gradually tapered down to the maintenance dose.
2. Cytostatics – used in very severe, resistant to treatment forms of this disease, e.g. methotrexate 12,5-25 mg once a week, preferably in combination with low doses of steroids.
3. Retinoids – vitamin A derivatives, used in severe cases involving mucous membranes, e.g. tretinoin, isotretinoin, etretinate and acitretin.
4. Sulfones – in combination with low doses of steroids, effective in bullous and erosive forms (dapsone 100 mg / d).
5. Cyclosporin A – a strong immunosuppressive drug, used in severe cutaneous and mucosal forms, initially in a dose of 2 times 25 mg for 7 days, then 25 mg / day, causes a significant improvement.
6. Levamisole – an immunomodulating drug, effective in an erosive form, located in the oral cavity, in combination with low doses of encorton; the use of this drug is limited due to possible hematological and neurological complications.
7. Photochemotherapy (PUVA) – one of the most frequently used methods of treating lichen planus; it consists in irradiating the lesions with long-wave ultraviolet radiation (UVA) after prior sensitization of the skin by orally administered psoralens (irradiation 3-4 times a week); bath-PUVA – bath in 8-methoxypsoralen solution is preceded by UVA irradiation, used in diffuse and adjuvant lesions; mouth-PUVA – psoralen preparations used in the form of a solution on the oral mucosa, which precedes UVA irradiation.
8. Neuroleptics and tranquilizers – started in patients due to persistent itching or nervous agitation.

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LITERATURE:

1. Braun-Falco O., Plewig G., Wolff HH, Burgdorf WHC: Dermatology, eds. half. Gliński W., Wolska H., Wydawnictwo Czelej, Lublin 2004, vol. 1, 593-599.

2. Jabłońska S., Majewski S .: Skin diseases and sexually transmitted diseases, PZWL, Warsaw 2006, 138-142.

3. Miklaszewska M., Wąsik F. (eds.): Pediatric Dermatology, Volumed, Wrocław 1999, 395-399.

4. Bała-Wojsznis A., Miękoś-Zydek B., Czyż P., Sulik M., Spinek A .: Red lichen planus – etiopathogenesis, clinic and modern treatment methods, Nowa Klinika 2003, 10, 1128-1133.

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