Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ONGOING

mild to moderate disease

1st line – topical corticosteroid or topical immunomodulator +/- emollient

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ONGOING
|
mild to moderate disease
1st line – 

topical corticosteroid or topical immunomodulator +/- emollient

Mild to moderate disease includes patients with small lesions, minimal or no symptoms, and no associated internal involvement. Topical corticosteroids and immunomodulators (e.g., tacrolimus) are equally effective as initial treatment.

Topical corticosteroids are useful to decrease skin inflammation and accompanying pruritus.[4] Lower- to moderate-potency agents (e.g., hydrocortisone, triamcinolone) should be used on the face, groin, and intertriginous areas. Higher-potency agents (e.g., clobetasol) can be used for up to 2 weeks and should be used with caution in the paediatric population. 

Possible side effects of topical corticosteroids include irritation, atrophy, telangiectasias, striae and pigmentary alterations. When using high-potency topical corticosteroids for large surface areas and over long periods, there is a risk of systemic absorption and hypothalamic-pituitary-adrenal axis suppression.

Topical tacrolimus has been effectively used for pityriasis lichenoides.[29] It has several anti-inflammatory properties by decreasing cytokine expression in the skin.[29]

The most common side effects seen with the use of tacrolimus are erythema, burning, and allergic skin reactions.[29] Rare severe side effects include eczema herpeticum and flu-like symptoms.

General skin emollients can be useful for occasional xerosis.

Primary options

hydrocortisone topical: (2.5%) children and adults: apply to the affected area(s) twice to four times daily

OR

triamcinolone topical: (0.1%) children and adults: apply to the affected area(s) twice to four times daily

OR

clobetasol topical: (0.05%) children ≥12 years of age and adults: apply to the affected area(s) twice daily for up to 2 weeks, maximum 50 g/week

OR

tacrolimus topical: (0.03%) children ≥2 years of age and adults: apply to the affected area(s) twice daily; (0.1%) children ≥16 years of age and adults: apply to the affected area(s) twice daily

Consider – phototherapy

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ONGOING
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mild to moderate disease
Consider – 

phototherapy

Additional treatment recommended for SOME patients in selected patient group

Phototherapy is effective and safe in all age populations for pityriasis lichenoides.[4][25][26]​​​ It can be used if there is no response to the first-line treatment. The preferred therapy is narrowband UVB without topical or systemic psoralens.[25][27]​​​

Phototherapy can be administered as narrow or broadband UVB, UVA1, or psoralen and UVA (PUVA; topical or oral).[1] The mechanism of action of light therapy is cross-linking DNA to prevent DNA synthesis and inhibiting the activity and action of inflammatory cells in the skin. Most common side effects of phototherapy are phototoxicity and skin thickening. Oral PUVA can also cause nausea, headache, and hypotension. 

Consider – oral antihistamine

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ONGOING
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mild to moderate disease
Consider – 

oral antihistamine

Additional treatment recommended for SOME patients in selected patient group

Oral antihistamines may be tried to reduce symptoms of pruritus and burning.[1]​ However, some experts believe they are not effective.

Cetirizine is a second-generation minimally sedating H1-antagonist that can be administered to adults and children.

The most common side effects of antihistamines are somnolence, dry mouth, abdominal discomfort, dizziness, and headache. Significant and very rare side effects include hypersensitivity reaction and hepatitis, arrhythmias, and heart failure.

Primary options

cetirizine: children 6-11 months of age: 2.5 mg orally once daily when required; children 12-23 months of age: 2.5 mg orally once or twice daily when required; children 2-5 years of age: 2.5 to 5 mg orally once daily (or 2.5 mg orally twice daily) when required; children ≥6 years of age and adults: 5-10 mg orally once daily when required

Consider – discontinuation of offending agent

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ONGOING
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mild to moderate disease
Consider – 

discontinuation of offending agent

Additional treatment recommended for SOME patients in selected patient group

If the clinician suspects medication as a potential culprit for pityriasis lichenoides, discontinuation of this medication is a logical solution.

Consider – antimicrobial therapy

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ONGOING
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mild to moderate disease
Consider – 

antimicrobial therapy

Additional treatment recommended for SOME patients in selected patient group

If the suspected trigger is a known infectious pathogen, antimicrobial therapy targeting that pathogen is the optimal treatment of choice. Some studies support the use of antimicrobials regardless of the trigger.[25]

Tetracycline, doxycycline, and erythromycin have shown utility in pityriasis lichenoides.[1][4]​ These agents may be especially advantageous in pityriasis lichenoides due to their anti-inflammatory properties.[4]​ Azithromycin is another antimicrobial option; one study found that azithromycin was comparable to narrowband UVB in terms of treatment efficacy among patients with pityriasis lichenoides chronica.[6]​ Erythromycin is a better choice in the paediatric population, due to the possible dental side effects linked to tetracyclines.

A gradual taper of these antibiotics is also advised to avoid disease recurrences.

Primary options

tetracycline: adults: 250-500 mg orally twice daily for 2-3 months, followed by 250-500 mg once daily

OR

doxycycline: adults: 50-100 mg orally twice daily for 2-3 months, followed by 50-100 mg once daily

OR

erythromycin base: children: 30-50 mg/kg/day orally given in 1-2 divided doses; adults: 250-500 mg orally twice daily for 2-3 months, followed by 250-500 mg once daily

Secondary options

azithromycin: adults: consult specialist for guidance on dose

More

severe disease or treatment resistance

1st line – systemic corticosteroid or immunomodulator ± supportive care

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ONGOING
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severe disease or treatment resistance
|
adults
1st line – 

systemic corticosteroid or immunomodulator ± supportive care

Severe disease includes patients with medium-to-large lesions, pruritic or painful lesions and those associated with constitutional symptoms.

Patients with severe disease should be seen by a dermatologist and treated with systemic medications such as corticosteroids, methotrexate, ergocalciferol, pentoxifylline, tiabendazole, dapsone, immunoglobulin, and retinoids.[1][4][25]​​[28]​ These medications carry significant side effects and should be used as a last line of treatment, and closely monitored with appropriate laboratory tests. They play a vital role in immunosuppression and anti-proliferation, which are important in improving pityriasis lichenoides.

High-dose immunosuppressive therapy with intensive and supportive care is required to manage the febrile ulceronecrotic Mucha-Habermann disease variant of the disease. Fulminant febrile ulceronecrotic Mucha-Habermann disease pityriasis lichenoides should be managed as a dermatological emergency because it usually requires acute hospital care and intensive or burn unit monitoring, with proper wound care of the necrotic skin lesions. Consult a specialist for guidance on the most appropriate immunosuppressive regimens for these patients (combination therapy may be required).

Primary options

prednisolone: consult specialist for guidance on dose

Secondary options

methotrexate: consult specialist for guidance on dose

OR

ergocalciferol: consult specialist for guidance on dose

OR

pentoxifylline: consult specialist for guidance on dose

OR

tiabendazole: consult specialist for guidance on dose

OR

dapsone: consult specialist for guidance on dose

OR

normal immunoglobulin human: consult specialist for guidance on dose

OR

acitretin: consult specialist for guidance on dose

1st line – systemic corticosteroid or methotrexate ± supportive care

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ONGOING
|
severe disease or treatment resistance
|
children
1st line – 

systemic corticosteroid or methotrexate ± supportive care

Severe disease includes patients with medium-to-large lesions, pruritic or painful lesions and those associated with constitutional symptoms.

Systemic corticosteroids or methotrexate can be used in rare refractory or severe cases of pityriasis lichenoides in children.[1][4]​ However, they carry significant side effects and should be used as a last line of treatment, especially in children, and closely monitored with appropriate laboratory tests. They play a vital role in immunosuppression and anti-proliferation, which are important in improving pityriasis lichenoides.

High-dose immunosuppressive therapy with intensive and supportive care is required to manage the febrile ulceronecrotic Mucha-Habermann disease variant of the disease. Fulminant febrile ulceronecrotic Mucha-Habermann disease pityriasis lichenoides should be managed as a dermatological emergency because it usually requires acute hospital care and intensive or burn unit monitoring, with proper wound care of the necrotic skin lesions. Consult a specialist for guidance on the most appropriate immunosuppressive regimens for these patients.

Primary options

prednisolone: consult specialist for guidance on dose

Secondary options

methotrexate: consult specialist for guidance on dose

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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