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

ACUTE

cutaneous disease

1st line – topical or intralesional corticosteroid

Back
ACUTE
|
cutaneous disease
1st line – 

topical or intralesional corticosteroid

In mild cases, potent topical corticosteroids are used as first-line therapy.[55]​​

Hypertrophic LP plaques may benefit from potent topical corticosteroids under occlusion or intralesional corticosteroids.

Tapering down topical corticosteroid strength/dosage at the earliest possible opportunity is important to avoid its cutaneous adverse effects. The risk of adrenal suppression is low unless LP is extensive.

Primary options

clobetasol topical: (0.05%) apply to the affected area(s) twice daily, maximum 50 g/week

OR

betamethasone dipropionate topical: (0.05%) apply to the affected area(s) once or twice daily

OR

triamcinolone acetonide: consult specialist for guidance on intralesional dose

Consider – antihistamine

Back
ACUTE
|
cutaneous disease
Consider – 

antihistamine

Treatment recommended for SOME patients in selected patient group

Consider using antihistamines as an adjunct to reduce itch.

Primary options

chlorpheniramine: 8 mg (extended-release) orally two to three times daily when required, maximum 24 mg/day

OR

diphenhydramine: 25-50 mg orally every 6-8 hours when required, maximum 300 mg/day

Consider – topical antipruritic

Back
ACUTE
|
cutaneous disease
Consider – 

topical antipruritic

Treatment recommended for SOME patients in selected patient group

Consider topical antipruritic agents (e.g., doxepin, menthol, camphor) as an adjunct treatment to reduce itch.[55]​ Various formulations of menthol and camphor are available without a prescription, and formulations vary.

Primary options

doxepin topical: (5%) apply to the affected area(s) four times daily (at least 3-4 hours apart) for up to a maximum of 8 days

2nd line – oral corticosteroid or retinoid or phototherapy

Back
ACUTE
|
cutaneous disease
2nd line – 

oral corticosteroid or retinoid or phototherapy

Severe forms of the disease (i.e., 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.

Systemic corticosteroids also remain a popular strategy for recalcitrant LP. Consultation with a specialist is recommended for dosing and treatment duration for longer term use.

Oral retinoids (e.g., acitretin) have been documented as an effective second-line therapy.[58]

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

Consultation with a specialist is recommended before initiating systemic treatment.

Primary options

prednisone: 30-80 mg orally once daily for 4-6 weeks, then taper gradually according to response

Secondary options

acitretin: 20-35 mg orally once daily

Consider – antihistamine

Back
ACUTE
|
cutaneous disease
Consider – 

antihistamine

Treatment recommended for SOME patients in selected patient group

Consider using antihistamines as an adjunct to reduce itch.

Primary options

chlorpheniramine: 8 mg (extended-release) orally two to three times daily when required, maximum 24 mg/day

OR

diphenhydramine: 25-50 mg orally every 6-8 hours when required, maximum 300 mg/day

Consider – topical antipruritic

Back
ACUTE
|
cutaneous disease
Consider – 

topical antipruritic

Treatment recommended for SOME patients in selected patient group

Consider topical antipruritic agents (e.g., doxepin, menthol, camphor) as an adjunct treatment to reduce itch.[55]​ Various formulations of menthol and camphor are available without a prescription, and formulations vary.

Primary options

doxepin topical: (5%) apply to the affected area(s) four times daily (at least 3-4 hours apart) for up to a maximum of 8 days

Consider – phototherapy added to oral corticosteroid or retinoid

Back
ACUTE
|
cutaneous disease
Consider – 

phototherapy added to oral corticosteroid or retinoid

Treatment recommended for SOME patients in selected patient group

Phototherapy (in the form of broad or narrowband UVB, oral or bath photochemotherapy with psoralen [PUVA] and UVA1 phototherapy) can be used as a treatment adjunct in patients not already being treated with phototherapy.[59][60][61][62] Considering the potential adverse effects, UVB is often preferred over PUVA.

3rd line – immunosuppressant/immunomodulator

Back
ACUTE
|
cutaneous disease
3rd line – 

immunosuppressant/immunomodulator

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

Oral cyclosporine 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., calcipotriene) 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]​​

Consultation with a specialist is recommended before initiating systemic treatment.

Primary options

cyclosporine modified: 3-5 mg/kg/day orally given in 2 divided doses

Secondary options

tacrolimus topical: (0.03% or 0.1%) apply to the affected area(s) twice daily for 1-2 months

OR

pimecrolimus topical: topical: (1%) apply to the affected area(s) twice daily for 1-2 months

OR

calcipotriene topical: (0.005%) apply to the affected area(s) once or twice daily

OR

mycophenolate mofetil: 0.5 to 1 g orally twice daily

OR

azathioprine: 1-2 mg/kg/day orally given in 1-2 divided doses

OR

methotrexate: 15-20 mg orally/subcutaneously/intramuscularly once weekly on the same day of each week

OR

griseofulvin microsize: 500-1000 mg/day orally given in 1-4 divided doses

OR

metronidazole: 250 mg orally three times daily for 12 weeks

OR

sulfasalazine: 1.5 g orally once daily initially, increase by 0.5 g/day increments every week according to response for 4-16 weeks, maximum 3 g/day

OR

hydroxychloroquine sulfate: 200-400 mg/day orally given in 1-2 divided doses

OR

enoxaparin: consult specialist for guidance on dose

Consider – antihistamine

Back
ACUTE
|
cutaneous disease
Consider – 

antihistamine

Treatment recommended for SOME patients in selected patient group

Consider using antihistamines as an adjunct to reduce itch.

Primary options

chlorpheniramine: 8 mg (extended-release) orally two to three times daily when required, maximum 24 mg/day

OR

diphenhydramine: 25-50 mg orally every 6-8 hours when required, maximum 300 mg/day

Consider – topical antipruritic

Back
ACUTE
|
cutaneous disease
Consider – 

topical antipruritic

Treatment recommended for SOME patients in selected patient group

Consider topical antipruritic agents (e.g., doxepin, menthol, camphor) as an adjunct treatment to reduce itch.[55]​ Various formulations of menthol and camphor are available without a prescription, and formulations vary.

Primary options

doxepin topical: (5%) apply to the affected area(s) four times daily (at least 3-4 hours apart) for up to a maximum of 8 days

Consider – phototherapy

Back
ACUTE
|
cutaneous disease
Consider – 

phototherapy

Treatment recommended for SOME patients in selected patient group

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

However, UVB should not be used with certain oral immunosuppressive drugs, including cyclosporine, azathioprine, and mycophenolate. UVB may be used with methotrexate in some patients.[84]

Consult a specialist for guidance when combining phototherapy with pharmacotherapy.

scalp disease

1st line – topical or intralesional or oral corticosteroid

Back
ACUTE
|
scalp disease
1st line – 

topical or intralesional or oral corticosteroid

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]

Tapering down corticosteroid strength or dose when able to is important to avoid side effects.

Long-term therapy has numerous potential risks.

Consultation with a specialist is recommended before initiating systemic treatment.

Primary options

clobetasol topical: (0.05%) apply to the affected area(s) once daily, maximum 50 g/week

OR

betamethasone dipropionate topical: (0.05%) apply to the affected area(s) once or twice daily

Secondary options

triamcinolone acetonide: consult specialist for guidance on intralesional dose

OR

prednisone: 30-80 mg orally once daily for 4-6 weeks, then taper gradually according to response

Consider – immunosuppressant

Back
ACUTE
|
scalp disease
Consider – 

immunosuppressant

Treatment recommended for SOME patients in selected patient group

Corticosteroid-sparing immunosuppressants can be used in combination with systemic corticosteroids in severe cases, dependent on specific patient situations.[67][68]​​[69]​​[70][71]​​​​​​

Corticosteroid dose can be reduced after the corticosteroid-sparing drug is started.

Malignancy risk is elevated with long-term use.

Regular routine blood tests are recommended.

Consultation with a specialist is recommended before initiating systemic treatment.

Primary options

cyclosporine modified: 3-5 mg/kg/day orally given in 2 divided doses

Secondary options

mycophenolate mofetil: 0.5 to 1 g orally twice daily

OR

azathioprine: 1-2 mg/kg/day orally given in 1-2 divided doses

2nd line – oral retinoid or tetracycline antibiotic

Back
ACUTE
|
scalp disease
2nd line – 

oral retinoid or tetracycline antibiotic

Second-line treatment options include oral retinoids (e.g., acitretin) or a tetracycline antibiotic (e.g., tetracycline).[6]

Consultation with a specialist is recommended before initiating systemic treatment.

Primary options

acitretin: 20-35 mg orally once daily

OR

tetracycline: 500 mg orally twice daily

2nd line – immunosuppressant

Back
ACUTE
|
scalp disease
2nd line – 

immunosuppressant

Immunosuppressants can be used as monotherapy in refractory cases.​[67]​​[68][69][70][71]​​​

Malignancy risk is elevated with long-term use.

Regular routine blood tests are recommended.

Consultation with a specialist is recommended before initiating systemic treatment.

Primary options

cyclosporine modified: 3-5 mg/kg/day orally given in 2 divided doses

Secondary options

mycophenolate mofetil: 0.5 to 1 g orally twice daily

OR

azathioprine: 1-2 mg/kg/day orally given in 1-2 divided doses

oral disease

1st line – topical corticosteroid ± oral corticosteroid

Back
ACUTE
|
oral disease
1st line – 

topical corticosteroid ± oral corticosteroid

Atrophic/ulcerative oral LP is best treated with topical corticosteroid preparations formulated for oral use.[72][74][85][86][87][88][89]

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

Some physicians recommend dissolving oral prednisone or betamethasone tablets in water and using as a mouthwash.

Oropharyngeal candidiasis can be prevented by concomitant topical antifungal therapy.

Consultation with a specialist is recommended before initiating systemic treatment.

Primary options

triamcinolone topical: (0.1% in orabase) apply sparingly to the affected area(s) two to three times daily

OR

clobetasol topical: (0.05% in orabase) apply sparingly to the affected area(s) twice daily

Secondary options

prednisone: 30-80 mg orally once daily for 4-6 weeks, then taper gradually according to response

-- AND --

triamcinolone topical: (0.1% in orabase) apply sparingly to the affected area(s) two to three times daily

or

clobetasol topical: (0.05% in orabase) apply sparingly to the affected area(s) twice daily

Consider – symptom relief

Back
ACUTE
|
oral disease
Consider – 

symptom relief

Treatment recommended for SOME patients in selected patient group

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 nonulcerative LP is best treated with barrier agents and/or a topical anesthetic 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., acetaminophen) may provide pain relief in certain patients; however, as nonsteroidal anti-inflammatory drugs may worsen symptoms, a specialist should be consulted before deciding on appropriate analgesia.

Primary options

benzydamine topical: (0.15%) 15 mL swished in the mouth and spit out every 3 hours when required

OR

lidocaine oropharyngeal viscous solution: (2%) 15 mL every 3 hours when required (swish around in mouth and spit out), maximum 8 doses/day

OR

aloe (Aloe vera): apply to the affected area(s) twice daily

OR

acetaminophen: 325-1000 mg every 4-6 hours when required, maximum 4000 mg/day

2nd line – immunosuppressant/immunomodulator or retinoid

Back
ACUTE
|
oral disease
2nd line – 

immunosuppressant/immunomodulator or retinoid

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

Malignancy risk is elevated with long-term use of immunosuppressants and regular routine blood tests are recommended.

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]

Consultation with a specialist is recommended before initiating systemic treatment.

Primary options

tacrolimus topical: (0.03% or 0.1%) apply to the affected area(s) twice daily for 1-2 months

OR

pimecrolimus topical: (1%) apply to the affected area(s) twice daily for 1-2 months

OR

tretinoin topical: (0.05% to 0.1%) apply sparingly to the affected area(s) once daily

OR

acitretin: 25-50 mg orally once daily

OR

sulfasalazine: 2.5 g/day orally given in 2-4 divided doses for 6 weeks

OR

azathioprine: 1-2 mg/kg/day orally given in 1-2 divided doses

OR

hydroxychloroquine sulfate: 200-400 mg/day orally given in 1-2 divided doses

OR

mycophenolate mofetil: 0.5 to 1.5 g orally twice daily

OR

methotrexate: 15 mg orally/subcutaneously/intramuscularly once weekly on the same day of each week

3rd line – alternative immunosuppressant/immunomodulator

Back
ACUTE
|
oral disease
3rd line – 

alternative immunosuppressant/immunomodulator

Cyclophosphamide, thalidomide, antibiotics (e.g., metronidazole, tetracyclines), itraconazole, dapsone, or biologics (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]

Consultation with a specialist is recommended before initiating systemic treatment.

Primary options

cyclophosphamide: 100 mg orally once daily

OR

thalidomide: 50-100 mg orally once daily initially, gradually decrease dose to minimal effective dose

OR

metronidazole: 250 mg orally three times daily for 1-3 months

OR

tetracycline: 500 mg orally twice daily for 1-3 months

OR

doxycycline: 100 mg orally twice daily for 1-3 months

OR

itraconazole: 200 mg orally twice daily for 1 week of each month for 3 months

OR

dapsone: 50 mg orally once daily for the first 15 days, followed by 100 mg once daily

OR

adalimumab: consult specialist for guidance on dose

OR

etanercept: consult specialist for guidance on dose

genital disease

1st line – topical corticosteroid or calcineurin inhibitor

Back
ACUTE
|
genital disease
1st line – 

topical corticosteroid or calcineurin inhibitor

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

Topical calcineurin inhibitors may be used 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.

Treatment for up to a few weeks may be required.

Primary options

clobetasol topical: (0.05%) apply to the affected area(s) twice daily, maximum 50 g/week

OR

betamethasone dipropionate topical: (0.05%) apply to the affected area(s) once or twice daily

Secondary options

tacrolimus topical: (0.03% or 0.1%) apply to the affected area(s) twice daily for 1-2 months

OR

pimecrolimus topical: (1%) apply to the affected area(s) twice daily for 1-2 months

Consider – symptom relief

Back
ACUTE
|
genital disease
Consider – 

symptom relief

Treatment recommended for SOME patients in selected patient group

Local anesthetic gel (e.g., lidocaine) or sedating antihistamines may be considered as adjunct treatments to ease discomfort.[55]​ Low-dose tricyclic antidepressants or anticonvulsants may be considered as secondary options.[55]

Consult a specialist for further guidance on suitable options for these patients.

Consider – graded vaginal dilators

Back
ACUTE
|
genital disease
Consider – 

graded vaginal dilators

Treatment recommended for SOME patients in selected patient group

The American College of Obstetricians and Gynecologists guideline recommends using graded vaginal dilators in conjunction with intravaginal topical corticosteroids to prevent vaginal adhesions and stenosis.[28]

Consider – oral corticosteroid

Back
ACUTE
|
genital disease
Consider – 

oral corticosteroid

Treatment recommended for SOME patients in selected patient group

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.

Consultation with a specialist is recommended before initiating systemic treatment.

Primary options

prednisone: 30-80 mg orally once daily for 4-6 weeks, then taper gradually according to response

nail disease

1st line – topical or intralesional corticosteroid

Back
ACUTE
|
nail disease
1st line – 

topical or intralesional corticosteroid

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 anesthetic.[82]​​

Primary options

clobetasol topical: (0.05%) apply to nail fold twice daily, maximum 50 g/week

OR

betamethasone dipropionate topical: (0.05%) apply to nail fold once or twice daily

Secondary options

triamcinolone acetonide: consult specialist for guidance on intralesional dose

2nd line – systemic corticosteroid or immunosuppressant

Back
ACUTE
|
nail disease
2nd line – 

systemic corticosteroid or immunosuppressant

Systemic corticosteroids may be used as second-line treatment.[54][83]​​​ Oral prednisone or intramuscular triamcinolone may help particularly with multiple nail involvement.

Cyclosporine and azathioprine may also be considered, particularly in erosive nail disease.[82]

Consultation with a specialist is recommended before initiating systemic treatment.

Primary options

prednisone: 30-80 mg orally once daily for 4-6 weeks, then taper gradually according to response

OR

triamcinolone acetonide: 0.5 mg/kg intramuscularly every 30 days, then taper gradually according to response

Secondary options

cyclosporine modified: 3 mg/kg/day orally given in 2 divided doses

OR

azathioprine: 1-2 mg/kg/day orally given in 1-2 divided doses

back arrow

Choose a patient group to see our recommendations

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

Use of this content is subject to our disclaimer