Lichen Planus: Causes, Symptoms, Treatment & Nutrition

What is Lichen Planus?

Lichen planus is a disease of the skin and/or the mucous membranes with the characteristic rash with popular, purple, polygonal and peripheral spaced lesions. [1]

Lichen Planus
Figure 2: Clinical photographs showing (a) Violaceous flat-topped papules and plaques of classical lichen planus (b) Reticular plaque-type mucosal lichen planus involving tongue and cheek mucosa Credits: https://www.openi.nlm.nih.gov

There was no racial predisposition associated with lichen planus. The disease affects equally men and women. Most often the symptoms begin between the ages of 30 and 60, however, lichen planus can occur at any age. In particular areas of the skin lichen planus occurs more frequently during winter months.

This skin condition is a relatively common and comes in episodes lasting months to years

Lichen planus is thought to be an autoimmune disease. The particular factor that causes the immune system to behave in such a fashion is unknown.

Lichen planus can be accompanied with other diseases. It is thought to be the result of an autoimmune process with an unknown initial trigger. These conditions include ulcerative colitis, alopecia areata, vitiligo, dermatomyositis, morphea, lichen sclerosis, and myasthenia gravis.[9]

There is an established connection between lichen planus and viral hepatitis C infection [8], chronic active hepatitis and primary biliary cirrhosis. (Study concluded that Lichen planus is associated with hepatitis C but not with hepatitis B!)

„Statistics have shown that about 16% patients with lichen planus also suffered from hepatitis C virus infection. This, in turn, indicates that individuals with liver anomalies fall easy prey to LP”[11]

Figure 7: Distribution of study subjects according to site-specific distribution of Oral Lichen Planus among the cases; Credits: www.openi.nlm.nih.gov

The very beginning of noticeable symptoms or their exacerbation is also associated with stressful events.

Some patients with lichen planus have a family history related to the disease. It was found that in families affected by this condition, there is a higher frequency of human leukocyte antigen B7 (HLA-B7). Other studies have found an association between Idiopathic Lichen Planus and human leukocyte antigen DR1 (HLA-DR1) and human leukocyte antigen DR10 (HLA-DR10). This means that lichen planus may be influenced by genetic predisposition. [13]

Symptoms and signs 

Lichen planus is localized symmetrically on the flexor surfaces (A surface brought closer together when a jointed structure is bent at a joint.) of the extremities, such as the wrists, forearms, calves, as well as truncus head, lumbar area, genitals and oral mucosa.

Lichen Planus Types
fig2: (a) Reticular Oral Lichen Planus: reticulated white striae of the lower lip proper; (b) plaque-type Oral Lychen Planus: confluent white reticulated plaques of the lateral tongue; (c) erosive Oral Lichen Planus: superficial erosions and white striae of the lower lip proper (courtesy of Dr. Peter Lynch); (d) vulvar Lichen Planus: superficial erosions at the vulvar introitus with fusion of the labia minora and vaginal stenosis; Figures 1(a) and 1(b) are reprinted with permission from [5]
Credits: www.openi.nlm.nih.gov
The typical rash is a flat papule with polygonal or oval shape, which has pinkish-red to deep red-purple color (in older lesions). The size varies – from the size of a pinhead to a small coin.

Papules (a small pimple or swelling on the skin), are separately standing or confluent in irregular patches.

Their surfaces are usually shiny, with specific whitish stripes or reticulated structures and some of the papules are covered with whitish scales. The rash affecting the hairy parts of the head skin causes atrophic skin changes with thinning or total loss of hair (cyclic alopecia). On the palms and soles may also appear yellowish papules with solid consistency.

Itching is very common in lichen plan but varies in severity depending on the type of the lesions and the degree of involvement. Hypertrophic (well developed) lesions are extremely itchy.

On average, oral mucosa is being affected in 50% of all patients with lichen planus. Most often the appearance of the oral mucosa is whitish with reticulated fern lesions in the form of plaques that are slightly infiltrated.

Oral lesions may be asymptomatic or can cause a burning sensation. If erosions develop over time, the patient may experience pain.

Genital papules are usually pink, often in groups of several papules.

Nails can also get infected and on their surfaces, the patients may notice longitudinal stretches and subungual hyperkeratosis.

In more than 50% of all patients with lichen planus lesions disappear within six months. However, it has been found that oral lichen planus may have an average duration of 5 years.

Lichen planus is a self-limiting disease, which usually resolves within 8-12 months and may appear again after particular periods of time. Mild cases can be treated with fluorinated topical corticosteroids. In severe cases, especially those where scalp, nails and mucous membranes are affected, may require more intensive therapy – oral corticosteroids, retinoids such as Soriatane and Accutane, immunosuppressants, antibiotics, physical therapy (PUVA-therapy, acupuncture etc.).

 

Diagnosis

Usually, the diagnosis of lichen planus is made by a dermatologist, oral surgeon or dentist on the basis of the typical clinical appearance. A skin biopsy may be needed to confirm the diagnosis.

Diagnosis of lichen planus is based on the clinical picture – skin, mucous and nail lesions, typical localizations of rashes, Köbner’s phenomenon, strong itching. A comprehensive study is needed to detect the provoking factors – outbreaks of chronic infections, diseases of the nervous system, endocrine disorders [10].

Nail and hair involvement

In about 10% of the patients, affected by lichen planus, there are multiple nail changes observed. There may be severe damages to the nail plate and matrix. Usually, such damage does not affect all the fingernails and toenails. When lichen planus causes some sort of nail deformation, patients often treat their nails with antifungal formulations because the nail changes are very similar to a fungal infection: longitude nail riding and grooving, splitting, nail thinning and nail loss. In severe cases, the nail may be temporarily or permanently destroyed – all those are often considered as symptoms of nail fungus.

As mentioned above, the scalp is often involved causing progressive scarring alopecia. Scarring alopecia is a disorder that destroys the hair follicle and replaces it with scar tissue. Hair loss may be slowly progressive over many years, sometimes even unnoticed for long periods. Or the hair loss may be rapidly destructive within months and associated with severe itching, pain, and burning. Immediate treatment is required. Such treatment includes oral steroids (which would stop the inflammation process), topical steroid liquids which should be applied directly on the affected areas, and oral medications such as  Accutane or Hydroxychloroquine.

Lichen Planus Hair
Figure 3: Clinical photographs showing (a) Peri-follicular lichenoid papules of follicular lichen planus with loss of hair at places (b) Lichen planus involving scalp with scarring alopecia and lichenoid infiltrated plaques; Source: www.openi.nlm.nih.gov

Treatment

Lichen planus symptoms (papules) normally go away within a year. However, treatment can make your skin look better. The goal of treatment is to reduce your symptoms and speed healing of the skin lesions. Sometimes, when the bumps are not very disturbing and do not lower one’s self-esteem, no particular treatment may be needed. Remedies can relieve the itching and improve the appearance of the rash until it goes away. Usually, topical corticosteroids have an immediate effect on the affected area.

In case the scalp is affected by the disease, the visible symptoms (partial baldness) must be treated right away, or the hair of the affected area may never grow back again.  You can use a corticosteroid ointment or cream that you apply directly to the lesions.Corticosteroids may also be injected into the affected area.

Erosive oral lesions and widespread itchy skin lesions usually require the oral ingestion of a systemic corticosteroid (e.g., oral prednisone). Unfortunately, skin lesions may reoccur after systemic prednisone has been stopped. In this case, a continued low dosage of a systemic corticosteroid may be prescribed.

Photochemotherapy with 8-methoxypsoralen and long-wave ultraviolet light (PUVA) [12] is the usual method for oral lichen planus treatment.

Usually, people can manage mild cases of lichen planus at home, without the need of medical intervention. If the condition causes pain or severe itching, prescription drugs may be needed

Home remedies for lichen planus

  • One of the most popular treatment methods for lichen planus affecting the facial skin is salt water. Dilute 1-2 tbsp of sea salt in water and add 1 tbsp pine needles infusion or birch leaves mixed with raw lemon juice to it. Before the application (mixture should be soaked into a cotton pad) of the ingredients, the face should be washed with mild soap and water and cleaned with cosmetic milk.
  • Fresh juice extracted from Basil leaves can be applied on the facial area where the skin is affected by lichens. Its’ anti-inflammatory and anti-bacterial properties can cure the disturbing symptoms for a couple of days.
  • Crush equal parts of green walnut husks and dock roots. Apply the mash on the affected area. Repeat the same procedure every day, for at least a week.
  • Prepare a paste of turmeric [2] powder diluted in some water. Apply on the affected facial areas in order to soothe the existing lesions and prevent further rashes. You can also use the pasta to the sores in your mouth: apply the ‘ointment’ with your fingers or even use an earbud to reach other areas of your mouth that your finger can’t access.
  • Beaten egg white mixed with 2-3 tbsp apple cider vinegar will provide immediate relief of the disturbing itch. The combination will also tighten the skin, respectively, the lesions that have already formed.
  • Aloe Vera: As considered as ‘the healing plant’ for its’ anti-inflammatory, antioxidant and antibacterial properties, Aloe vera [3] gel can be applied topically to the lesions. The clinical trial also informs that the plant is also very effective in the treatment of oral lichen planus. Simply cover your tongue or gums with the gel throughout the day and it will relieve burning sensation,  soreness, and ulcers.

„A good or complete clinical response was seen in 88% of patients receiving aloe vera compared with 4% receiving placebo [4]

  • Hydrogen Peroxide [6] as a topical wash mixed 1:1 with water. Hydrogen Peroxide is a bleaching agent and is used in a lot of women’s cosmetic whitening creams and also used in whitening teeth products. Choose 3% Hydrogen Peroxide that you can find in any grocery or pharmacy anything stronger is dangerous. Hydrogen Peroxide will dry out the skin if used very often, so do not wash your face with the mixture more than once a month.
  • Soaking in an oatmeal bath for about 10 to 15 minutes each day can also suppress the symptoms. You can also apply oatmeal paste (blend the oatmeal and add some water) on your face daily.
  • Cool compress applied on the lesions will provide immediate relief from the itchy sensation

Genital Lichen Planus

The usual symptoms are soreness, burning, and rawness. If the outer layers of the skin break down, these areas appear moist and red. The following tips are very effective if you are affected by genital lichen planus.

  • Wash with plain warm water, it would be better not to use soap
  • Use a good lubricant during sexual intercourse, there are many on the market such as YES, Astroglide, V Gel and Sensilube to name a few, these products are mucous like and very moisturizing

Try wearing stockings instead of tights and go without underwear wherever possible

Over the counter treatment

Noble Formula Zinc Cream – Pyrithione Zinc (ZnP), 4 Oz (120ml)

This topical cream is specially formulated for relief of symptoms of psoriasis, eczema, lichen planus, seborrheic dermatitis and other conditions provoking skin swelling, itching, and redness. Product reviews are impressively positive; friendly more than 70% of all customers claim to experience immediate relief after topical application:

„The redness was calmed IMMEDIATELY. It has been 2 days – 48 hours – and every time I apply the cream I am impressed with the calming effect.”

DermaZinc Zinc Therapy Soap 120g bar

According to many customers, after regular usage, their symptoms (such as flakes) dramatically increased. You can use it as a shampoo, face wash, and body wash. All the ingredients containing in the soap are skin – friendly: Active-2% Zinc Pyrithione. Other: Palm Oil, coconut oil, deionized water, sodium hydroxide, glycerine, zinc oxide, organic oatmeal, shea butter,
cocoa butter, olive oil, grapeseed oil, salt, vitamin E.

Emuaid© Natural, Pain Relief Ointment.

This product has a lot of reviews on the Web and, what is more important, they are mostly positive. The ointment is a bit pricey but most of the customers inform that they had a positive effect after the application of the cream.

However, there are customers who have experienced a reverse effect from treating their skin problems with this particular product:

„ Unfortunately it seems to make my daughter’s very sensitive skin more red and itchy.”

Noble Formula 2% Pyrithione Zinc (Zn) Bar Soap 3 Oz

This is another soap was specially developed for people with Psoriasis, Eczema, Dry and Sensitive Skin. It contains a high percentage of nourishing olive oil, moisturizing emu oil, and gently exfoliating oatmeal – all of these ingredients are recommended for treatment of lichen planus. Almost all of the reviews available claim that the soap bar soothes irritated skin. There are a lot of comments with pictures ‘before and after’ included which you could check yourselves:

‘‘I have been using this product for about a month now and I have seen a lot of improvement in the texture of my skin.’’

Nutrition

Though nutritional elements [7] are not a cure for the condition, some vitamins, minerals and enzymes, containing in particular foods may help reduce the risk of a lichen planus outbreak and treat symptoms of the condition. Here’s a list of some useful tips you should follow:

  • Avoid eating spicy foods and anything acidic, such as fruit juice, as they can irritate oral lichen planus
  • Avoid wheat, chocolate, or sugar
  • Minimize the consumption of dairy foods
  • Avoid eating sharp food, such as crusty bread in case you have oral lichen planus
  • If areas of your mouth are painful, stick to soft, bland foods, such as mashed vegetables and porridge

Sometimes it’s hard to figure out what foods cause Lichen planus flare-ups. However, it is considered that particular foods you consume may reduce the symptoms of the disease, while others (which you should avoid) may trigger and worsen the condition. Below, you can check more patients’ experiences with the disease:

„I have spent hours researching online and I try and follow the Paleo diet which is no wheat, no dairy, no sugar, no starch,  nothing processed.  It was really hard at first but has now become a way of life and means that I very very rarely itch or get a a new blister.”

„From the list of things recommneded, it seems  wheat,  sugar, fruit and vegetables and dairy all can trigger and even meat and some fish!”

„If I eat a lots of sugar and wheat can’t sleep from itching and I get new LP blisters/spots if I eat a bit in the morning (as I love my bread) I am ok during the night. ”

You can’t do much to prevent lichen planus, but once you have it, you can take some steps to keep it from getting worse. Below, there’s a list of some additional pieces of advice:

  • Avoid any sorts of injuries to your skin.
  • Limit the stress in your life. Chronic stress is a possible trigger as it makes your body produce cortisol.
  • For oral lichen planus, stop smoking, avoid alcohol, maintain good oral hygiene, and avoid any foods that seem to irritate your mouth.

Lichen planus is not a dangerous nor fatal disease, and it usually goes away on its own. Note that treatments aim to ease the symptoms and clear the rash, the milder cases do not require a particular treatment. However, in some people, even if successfully, the skin condition may occur again.

References

  1. https://en.wikipedia.org/wiki/Lichen_planus#Pattern
    Lichen planus lesions – different forms
  2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3961895/
    Turmeric – A new treatment option for lichen planus: A pilot study
  3. Aloe vera as cure for lichen planus
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3961895/
  4. Aloe Vera Gel Effective for Oral Lichen Planus
    http://www.journalnma.org/article/S0027-9684(15)31489-9/pdf
  5. http://www.pagepress.org/journals/index.php/dr/article/view/dr.2011.e4
    Garlic in dermatology
  6. http://www.curezone.org/forums/fm.asp?i=1347206
    Lichen Planus and Hydrogen Peroxide 3% H2O2
  7. http://www.nhs.uk/Conditions/Lichen-planus/Pages/Treatment.aspx
    Lichen planus – Treatment
  8. https://www.ncbi.nlm.nih.gov/pubmed/20666875
    A study on the association with hepatitis B and hepatitis C in 1557 patients with lichen planus
  9. https://www.aad.org/public/diseases/rashes/lichen-planus#symptoms
    The signs and symptoms of lichen planus
  10. https://rarediseases.org/rare-diseases/lichen-planus/
    Lichen planus Related Disorders
  11. https://www.symptoma.com/en/info/lichen-planus
    Lichen planus: Pathophysiology
  12. https://www.ncbi.nlm.nih.gov/pubmed/7600216
    Photochemotherapy of oral lichen planus. A controlled study.
  13. http://www.skindermatologists.com/lichen-planus.html
    Lichen Planus – genetic predisposition

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