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Lichen planus in Adult
See also in: Anogenital,Nail and Distal Digit
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Lichen planus in Adult

See also in: Anogenital,Nail and Distal Digit
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Contributors: Lauren Strazzula MD, Susan Burgin MD, Belinda Tan MD, PhD
Other Resources UpToDate PubMed

Synopsis

Lichen planus (LP) is a condition in which autoreactive T lymphocytes attack basal keratinocytes in the skin, mucous membranes, hair follicles, and/or nail units. The etiology is unclear, but viruses, medications, or contact allergens have all been implicated. LP is most common in adults in the fourth to sixth decades of life, but it may occur at any age. There is no known predilection for either sex or ethnicity.

Clinically, patients present with pruritic, flat-topped, pink to purple papules that are localized most commonly along the volar wrists, shins, presacral area, and hands, but may be widespread. Oral LP and/or LP involving the genitalia can occur in isolation or in patients with cutaneous disease. Lichen planopilaris, a variant of LP affecting the follicular unit, presents with perifollicular erythema and scaling and leads to scarring alopecia. (Frontal fibrosing alopecia is a variant that is seen in older women. Another rare variant is the Graham-Little-Piccardi-Lasseur syndrome.) LP can also affect the nail matrix, resulting in fissuring, longitudinal ridging, and lateral thinning of the nails.

Certain medications cause an LP-like eruption. Culprits include captopril, enalapril, labetalol, propranolol, methyldopa, calcium channel blockers, NSAIDs, chloroquine, hydroxychloroquine, quinacrine, thiazide diuretics, etanercept, infliximab, penicillamine, quinidine, and gold salts.

At the microscopic level, lichen planus and its many variants show a "lichenoid" pattern: a dense band of mononuclear cells obscuring the dermal-epidermal junction with vacuolar degeneration along the basal keratinocytes indicating immune-mediated apoptosis.

LP can spontaneously resolve, usually after a year, or follow a remitting or chronic course. It has been described in association with hepatitis C, predominantly in certain geographical areas (Japan and Mediterranean regions). Hepatitis B vaccination as well as exposure to other bacteria and viruses has also been associated with LP in the literature. Oral LP may occur on mucosal surfaces apposed to amalgams and other dental restorative materials.

Codes

ICD10CM:
L43.9 – Lichen planus, unspecified

SNOMEDCT:
4776004 – Lichen planus

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Diagnostic Pearls

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Differential Diagnosis & Pitfalls

In any location, consider drug-induced LP / lichenoid drug eruption. Characteristics of lichenoid drug reaction, as opposed to non-drug-associated LP, include older mean age, more generalized distribution, paucity of Wickham's striae, frequent photodistribution, sparing of mucous membranes, and distinct histologic characteristics.

Differential diagnosis of cutaneous LP:
Differential diagnosis of oral and mucosal LP:
Differential diagnosis of lichen planopilaris:
Differential diagnosis nail apparatus LP:

Best Tests

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Management Pearls

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Therapy

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Drug Reaction Data

Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.

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References

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Last Updated: 10/27/2016
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Lichen planus in Adult
See also in: Anogenital,Nail and Distal Digit
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Lichen planus : Forearm, Koebner phenomenon, Oral white plaque, Polygonal configuration, Purple color, Wrist, Anterior lower leg, Pruritus, Smooth papules
Clinical image of Lichen planus
Flat-topped violaceous, polygonal papules, some annular, with fine white scale at the wrist.
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