Lichen planus - Nail and Distal Digit
See also in: Overview,AnogenitalAlerts and Notices
Synopsis
Nail involvement occurs in less than 25% of patients with skin or mucosal disease. Isolated nail involvement can also be the first or only manifestation of the disease, but isolated nail LP is relatively uncommon. Clinical features depend on the location, duration, and severity of the disease in the nail apparatus. Involvement of the entire nail matrix is the most frequent presentation and results in thinning of the nail plate, onychorrhexis, nail atrophy with dorsal pterygium formation, and trachyonychia. Focal nail matrix involvement produces longitudinal splitting, longitudinal ridging, and pitting. Involvement of the nail bed is rare and induces distal subungual hyperkeratosis with or without associated onycholysis. If untreated, permanent scarring of the nail matrix may occur, resulting in dorsal pterygium formation.
LP is a cause of twenty-nail dystrophy, which is more commonly seen in children than adults. LP has been reported as a cause of longitudinal melanonychia.
Typically the diagnosis of nail LP is delayed, and many patients will have changes for more than 3 years before the diagnosis is made.
LP is more common in adults, and prevalence in children is 2%-3%.
Codes
ICD10CM:L43.9 – Lichen planus, unspecified
SNOMEDCT:
4776004 – Lichen planus
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Diagnostic Pearls
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Differential Diagnosis & Pitfalls
Nail matrix involvement:- Trachyonychia
- Lichen striatus
- Onychotillomania
- Morphea
- Systemic amyloidosis
- Impaired peripheral vascularization
- Nail alteration following toxic epidermal necrolysis
- Graft-versus-host disease
- Dyskeratosis congenita
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.Subscription Required
References
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Last Reviewed:05/23/2020
Last Updated:05/31/2020
Last Updated:05/31/2020
Patient Information for Lichen planus - Nail and Distal Digit
Overview
Lichen planus (LP) is a rash that affects the skin and, less often, the scalp, fingernails, toenails, and/or inside the mouth or genital area (mucous membranes). Lichen planus can resolve on its own without treatment, or it can be persistent, even with aggressive treatment.Who’s At Risk
People of any age, race / ethnicity, and sex can have lichen planus. However, it is rarely seen in young children and older adults; it is most common in people aged 30-60.Although the cause of lichen planus is unknown, some people with the condition also have hepatitis C, an infection of the liver.
People who take certain medications may develop drug-induced lichen planus. These medications include:
- High blood pressure (hypertension) medicines, including diuretics (eg, hydrochlorothiazide), ACE inhibitors (eg, lisinopril), and calcium channel blockers (eg, nifedipine).
- Diabetes medications, including sulfonylureas.
- NSAIDs such as ibuprofen (Advil, Motrin) and naproxen (Aleve).
- Antimalarial medications.
- Penicillamine.
- Tumor necrosis factor (TNF)-alpha inhibitors.
- Tyrosine kinase inhibitors.
Signs & Symptoms
The most common locations for lichen planus include the:- Inner wrists.
- Forearms.
- Inner ankles.
- Lower legs.
- Neck.
- Trunk.
- Mouth.
- Fingernails and toenails.
- Scalp.
- Genitals.
New lesions of lichen planus can be caused by injury to the skin.
Once lichen planus lesions heal, they often leave behind patches of dark gray skin, which are more pronounced in darker skin colors. These areas may take months to return to their normal color.
In the mouth, lichen planus appears as white streaks or patches (flat, smooth areas that are larger than a thumbnail), most often seen on the inner cheeks. Oral lichen planus is usually not painful, but in severe cases, there may be painful sores in the mouth.
When lichen planus involves the fingernails or toenails, the nails may become thick, or they may have splitting, ridges, or grooves. In severe cases, the entire nail may be destroyed.
On the scalp, lichen planus (called lichen planopilaris) may cause skin color change, irritation, and, in some cases, permanent hair loss.
On the genitals, lichen planus lesions may be quite tender and sores may develop, especially in women.
Self-Care Guidelines
- Apply over-the-counter hydrocortisone cream to help relieve skin itching in mild lichen planus.
- If you have lichen planus in the mouth, avoid drinking alcohol and using tobacco products.
When to Seek Medical Care
If you develop an itchy, bumpy rash, see a dermatologist or another medical professional for evaluation.If you have severe oral lichen planus, there is a very small chance of developing oral cancer, so you should see your dentist twice a year to check for cancer.
Treatments
Your medical professional will check your medication list to see if one of your medications may be the cause. If lichen planus is suspected, a dermatologist may want to perform a skin biopsy.In addition, one of the following treatments may be recommended:
- Topical corticosteroid cream, lotion, ointment, or gel, eg, prednisone (Rayos), betamethasone (Diprolene, Celestone), triamcinolone (Aristospan, Kenalog), or Halobetasol (Ultravate, Halonate)
- Corticosteroids injected directly into any thick lesions
- Oral antihistamine pills such as loratadine (Claritin), cetirizine (Zyrtec), fexofenadine (Allegra), desloratadine (Clarinex), hydroxyzine (Vistaril), or diphenhydramine (Benadryl) for itching
- Ultraviolet light treatment
- Topical tacrolimus (Protopic) or pimecrolimus (Elidel)
- Topical corticosteroid mouthwash, ointment, or gel
- Pain-relieving mouthwash
- Oral medications, such as prednisone, metronidazole (Flagyl), isotretinoin (Amnesteem, Claravis), acitretin (Soriatane), and hydroxychloroquine (Plaquenil)
Lichen planus - Nail and Distal Digit
See also in: Overview,Anogenital