Approach

A large number of medications of different types and forms are used in the treatment of lichen planus (LP); corticosteroids (topical/systemic), retinoids, calcineurin inhibitors, immunosuppressants, and phototherapy may all be used.[55]​ However, it is difficult to evaluate their efficacy, as most data come from small series of patients or anecdotes without adequate controlled trials.[55][56]​

In most cases, symptomatic treatment is usually sufficient, as spontaneous remission of cutaneous and oral LP can occur after varying periods of time. Consultation with a specialist is recommended before initiating systemic treatment. Systemic options are usually reserved for more severe disease, and many have undesirable adverse effects that require consideration by practitioners and patients.

Cutaneous disease

In mild cases, potent topical corticosteroids are used as first-line therapy.[55]​ Consider using oral antihistamines and/or topical antipruritic agents (e.g., doxepin, menthol, camphor) as an adjunct to reduce itch.[55]​ Hypertrophic LP plaques may benefit from potent topical corticosteroids under occlusion or intralesional corticosteroids. Severe forms of the disease (with marked irritation, widespread guttate LP) may require treatment with systemic corticosteroids.[2][57]​​​ Treatment may be continued for 2 to 6 weeks and then gradually tapered over several weeks. Tapering down topical/systemic corticosteroid strength/dosage at the earliest possible opportunity is important to avoid its cutaneous adverse effects. The risk of adrenal suppression with topical or intralesional treatment is low unless LP is extensive.

Second-line options

In the treatment of recalcitrant LP, systemic corticosteroids remain a popular strategy.[55]​ As a second-line treatment, the efficacy of oral retinoids (e.g., acitretin) is documented.[58] However, due to the recalcitrant nature of this disease category, relapse may occur after discontinuation and long-term maintenance therapy may be required.

Phototherapy (in the form of broad or narrowband UVB, oral or bath photochemotherapy with psoralen [PUVA], and UVA1 phototherapy) can be used as an effective second-line monotherapy or as a treatment adjunct.[59][60][61][62] Considering the potential adverse effects, UVB is often preferred over PUVA.

Third-line options

Numerous alternative treatment modalities exist, but evidence for these is limited.[63]

Oral ciclosporin is useful for inducing a remission in severe cases resistant to retinoids and systemic corticosteroid therapy.[64][65]​ However, long-term use is associated with renal toxicity and relapse of LP may occur on discontinuation.

Topical calcineurin inhibitors (e.g., tacrolimus, pimecrolimus) may also be considered, but data on efficacy for cutaneous LP are limited to case reports.[55][63]​ Because of the theoretical risk of potentiating malignant transformation, patients on topical calcineurin inhibitors need careful evaluation on follow-up. 

Topical vitamin D analogues (e.g., calcipotriol) may be useful as an alternative to topical corticosteroids, but evidence is very low quality.[63]

Examples of other agents used in the treatment of severe cutaneous LP include antifungals (e.g., griseofulvin), antibiotics (e.g., metronidazole), sulfasalazine, hydroxychloroquine, low-molecular-weight heparin (e.g., enoxaparin), and other immunosuppressants (e.g., azathioprine, mycophenolate, methotrexate).[55][63]​​​[66]

Scalp disease (Lichen planopilaris)

High-potency topical corticosteroids are used as first-line therapy.[56]​​[67][68]​​ However, intralesional corticosteroid injection (e.g., triamcinolone) may be more effective.[55]​ Systemic corticosteroids may be required for severe disease.[67][68]​ Second-line treatment options include oral retinoids and tetracycline antibiotics.[6]

Consider using corticosteroid-sparing immunosuppressants, such as mycophenolate or azathioprine, in combination with systemic corticosteroids or alone as a monotherapy for ongoing disease that is refractory to first- and second-line treatments.[67][68]​​[69][70][71]​​​

Oral disease

Asymptomatic non-ulcerative oral LP does not require treatment. The treatment aims of symptomatic oral LP are to heal areas of painful ulceration and blistering.[72] It is important that the patient maintains a high standard of oral hygiene and avoids any causes of oral trauma like ill-fitting dentures.

Symptomatic non-ulcerative LP is best treated with barrier agents and/or a topical anaesthetic as a mouth rinse or gel.[72] Agents to consider include benzydamine mouth rinse, topical lidocaine, and aloe vera gel.[72][73] Analgesics (e.g., paracetamol) may provide pain relief in certain patients; however, as non-steroidal anti-inflammatory drugs may worsen symptoms, a specialist should be consulted before deciding on appropriate analgesia.

Atrophic/ulcerative oral LP is best treated with topical corticosteroid preparations formulated for oral use.[55][74]​​​​ A variety of different agents may be used.[72]​​​​​​[75]​​ One Cochrane review found low-certainty evidence that topical corticosteroids are more effective at reducing pain compared with placebo; evidence on clinical effect and adverse effects was inconclusive.[76]​ Tapering down corticosteroid strength or dose when able is important to avoid side effects. Oropharyngeal candidiasis can be prevented by concomitant topical antifungal therapy.

Severe disease unresponsive to topical measures is usually treated with a short course of systemic corticosteroids, with topical oral corticosteroids as further maintenance.[72]

Other forms of treatment used for recalcitrant oral disease include sulfasalazine, azathioprine, hydroxychloroquine, topical or oral retinoids,​​​​​​​​ topical calcineurin inhibitors,​​​​​​​​​​​​ mycophenolate, or methotrexate, although data for efficacy are very limited.[55]​​[77][78]​ ​

One Cochrane review found very-low certainty evidence that tacrolimus may be more effective at resolving pain than corticosteroids.[76]​ Concerns have been expressed regarding the potential of tacrolimus to encourage malignant transformation of the mucosa, though the evidence for this is very limited.[79]​ Combined with the risk of malignant transformation in oral LP of around 1%, it is important to monitor patients treated with topical calcineurin inhibitors, particularly those with erosive and ulcerative lesions.[79]

Cyclophosphamide, thalidomide, antibiotics (e.g., metronidazole, tetracyclines), itraconazole, dapsone, or biologicals (e.g., adalimumab, etanercept) may be considered as third-line options.[55]​ Thalidomide is an agent with therapeutic and oral cancer prevention potentials, but data are limited.[80]

Genital mucosal disease

Potent topical corticosteroids remain the mainstay of treatment.[28][46]​​​[51]​​​​​​​​ The American College of Obstetricians and Gynecologists guideline recommends graded vaginal dilators in conjunction with intravaginal topical corticosteroids to prevent vaginal adhesions and stenosis.[28]​

Consider using topical calcineurin inhibitors as second-line therapy.[28]​​​[81]​​​​ Because of the theoretical risk of potentiating malignant transformation, patients on calcineurin inhibitors need careful evaluation on follow-up.

If initial treatments are ineffective, rule out alternative causes and refer for specialist treatment.[28]​ Systemic corticosteroids may be used for short periods in severe ongoing disease. However, dose requirements are higher in mucosal disease, and therefore consider potential adverse effects.

Local anaesthetic gel, sedating antihistamines, low-dose tricyclic antidepressants, or anticonvulsants may be considered as adjunct treatments to ease discomfort.[55]

There is a lack of evidence for alternative systemic treatment options. Limited data suggests hydroxychloroquine, methotrexate, mycophenolate, and retinoids may be effective; however, routine use is not recommended.[28][46]

Nail disease

Lichen planus affecting the nails can be challenging to treat and, after initial improvement, many patients are susceptible to relapse.[55]​ Potent topical corticosteroids rubbed into the nail fold may help in the active stages. Triamcinolone intralesional injections may be instilled into the proximal nail fold under local anaesthetic.[82]​

Systemic corticosteroids may be used as second-line treatment.[54][83]​​ Oral prednisolone or intramuscular triamcinolone may help particularly with multiple nail involvement. Also consider ciclosporin and azathioprine, particularly in erosive nail disease.[82]

Multiple lesion sites

There are no established guidelines for the treatment of patients with more than one form of lichen planus. These patients are treated subject to clinical judgement on a case-by-case basis.

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