EpistemisCutaneous lichen planus
Specialty: Skin.
Why it occurs
- Autoimmune reaction mediated by CD8+ T lymphocytes directed against the basal keratinocytes of the epidermis that express altered antigens (frequently associated with chronic active infection by the hepatitis C virus)
- Lichenoid reactions induced by drugs (antimalarials, thiazides, beta blockers)
- Acute emotional stress as an immunological trigger
- Occupational exposure to photographic developers based on gold salts
- Concomitant autoimmune collagen diseases.
Initial workup
Visual inspection looking for polygonal, purplish, flat and pruritic papules (the "4 P's" of lichen planus) with whitish streaks on the surface (Wickham's striae). Punch skin biopsy to confirm the diagnostic histopathology: interface dermatitis with band lymphocytic infiltrate at the dermal-epidermal junction, apoptotic keratinocytes (Civatte bodies) and wedge hypergranulosis. Complete serology for hepatitis C (Anti-HCV).
red flags
Presence of very painful erosive or ulcerated lesions located in the oral, esophageal or genital mucosa of long evolution that do not respond to topical corticosteroid therapy (high risk of malignant transformation to cutaneous or mucosal squamous cell carcinoma).
Standard management
- Clobetasol propionate 0.05% cream or ointment — corticosteroid of choice applied twice a day to control the inflammation and intense itching of the papules
- Hydroxyzine — H1 antihistamine for the management of intolerable nocturnal pruritus, dose of 25 mg orally at night
- Oral prednisone — indicated in very extensive acute outbreaks or mucosal erosive forms, dose of 0.5 mg/kg/day orally with a rapid decrease regimen
- Acitretin or cyclosporine (indicated in severe generalized refractory forms of cutaneous lichen planus).
Educational guidance for study. It is NOT a prescription recommendation. The actual choice depends on the cause, the patient, and current guidelines.
- Area
- Skin
- Listed causes
- 5
- Treatment options
- 4