Lichen Planus Treatment in Ankara, Turkey

Lichen planus is a non-contagious, chronic, and inflammatory disease that develops as a result of the immune system targeting the skin, mucous membranes, nails, and hair follicles. It is generally characterized by purplish, flat-topped, shiny bumps that suddenly appear on the wrists and ankles and are accompanied by severe itching. This autoimmune condition, in which the body’s defense mechanism mistakenly perceives its own healthy cells as a threat, may be confused with fungal infections or simple allergies, but its origin and treatment approach are completely different. This condition, which can affect not only the skin surface but also the inside of the mouth and the genital area, can be kept under control with dermatological follow-up and proper management.

What Is the Main Cause of Lichen Planus Disease?

To understand why this disease occurs, we need to take a closer look at our body’s defense mechanism. Lichen planus is an inflammatory disease with “autoimmune” characteristics in medical terms. Under normal conditions, the soldiers of the immune system, namely T cells, which are responsible for protecting our body against enemies such as viruses and bacteria coming from outside, become confused in this disease. These cells perceive the healthy cells at the point where the upper and lower layers of the skin meet as “foreign” and begin to attack them.

During this attack, the cells in the skin are damaged and an image of a battlefield is formed. When we dermatologists look at this tissue under the microscope, we see heavy cellular traffic in that area of the skin, that is, an accumulation of inflammatory cells. Although it is not known why the immune system suddenly declares war on its own skin, it is thought that environmental factors pull the trigger in genetically predisposed individuals. In other words, imagine a room full of loaded weapons genetically; for the disease to begin, someone has to pull that trigger. The factors that pull that trigger determine the course of the disease.

What Are the Factors That Trigger This Disease?

There are many different factors that play a role in the onset or flare-up of the disease. Sometimes our patients say, “I had nothing, and then it started suddenly,” but when a detailed inquiry is made, the underlying triggers come to light. Although these triggers vary from person to person, the groups we encounter most frequently are as follows:

• Hepatitis C virus
• Hepatitis B vaccine
• Flu vaccines
• Blood pressure medications
• Diuretics
• Antimalarial drugs
• Gold salts used in the treatment of rheumatism
• Amalgam dental fillings
• Chemical substances
• Intense stress
• Sadness and trauma

The relationship between Hepatitis C virus (HCV) and lichen planus is particularly interesting. While this association is seen very frequently in some countries, the rates are lower in our country. However, we still definitely investigate this viral factor, especially in our patients with resistant sores inside the mouth.

Drugs can also lead to a condition we call a “lichenoid reaction,” which mimics lichen planus. In this case, our greatest advantage is that the condition has a high likelihood of regressing when the suspected medication is discontinued. Mercury (amalgam) used in dental fillings can trigger the disease by creating a local allergic reaction, especially in oral lesions.

How Effective Is Stress on Lichen Planus?

The skin and nervous system originate from the same root during development in the womb. Therefore, it is inevitable that the storms breaking out in our emotional world will be reflected in our skin. In lichen planus patients, stress is not only a trigger but also a factor that increases the severity of the disease. Intense work pace, family problems, sudden shocks, or periods of depression can disrupt the balance of the immune system and initiate this autoimmune attack. A large number of our patients state that they experienced a serious stress factor in the period before their itching began. Therefore, during the treatment process, it is not enough just to apply cream to the skin; ensuring mental calmness is also an important part of healing.

What Are the Skin Symptoms and Lichen Planus Lesions Like?

The classic skin symptoms of lichen planus are quite typical. In dermatology, it is recognized by the features known as the “4 P” rule: Purple, Polygonal, Pruritic, Papule. It usually begins on the inner side of the wrists and the ankles, but it may spread to the waist area and the legs.

The most distinctive features of these lesions are:

• Purple color
• Flat top
• Shiny surface
• Angular shape
• Severe itching
• Symmetrical distribution

Itching is the symptom that troubles the patient the most. In fact, the more the patient scratches, the more they itch instead of finding relief, and new lesions appear in the scratched areas. We call this the “Koebner phenomenon.” In other words, if you traumatize healthy skin with your fingernails, the disease will spread there as well. For this reason, the first and most important advice we give our patients is “Please do not scratch.” When the lesions are examined carefully or a little oil is applied over them and they are examined with a magnifying glass, fine, white, lace-like networks called “Wickham striae” are seen. This finding provides us with great convenience in making the diagnosis.

What Are the Types of Lichen Planus?

The disease may not always present in its classic appearance. It has different subtypes according to the area where it is located and the character of the lesion. This diversity may sometimes cause delays in diagnosis because some types can be confused with other diseases such as fungal infections or eczema.

The most common clinical variants are as follows:

• Hypertrophic lichen planus
• Actinic lichen planus
• Annular lichen planus
• Inverse lichen planus
• Linear lichen planus
• Bullous lichen planus
• Atrophic lichen planus
• Pigmented lichen planus

The hypertrophic form is usually seen on the front of the legs, over the shinbone. Here, the lesions are very thick, their surfaces are rough, and the itching is unbearable. It is one of the most resistant forms to treatment and may leave dark spots in that area even after healing. The actinic form, on the other hand, is seen more often in sun-exposed areas, especially the face and neck, in the form of dark-colored rings, and is more common in dark-skinned individuals. The inverse form affects fold areas such as the armpits and groin, and because the classic scaling is not seen there due to moisture, diagnosis may become more difficult.

How Is Oral Lichen Planus Seen?

Lichen planus loves not only the skin but also the inside of the mouth and the genital area, which we call mucosa. In fact, in a significant number of cases, only oral involvement is seen. While the signs inside the mouth may sometimes progress very quietly, sometimes they may be severe enough to prevent the patient from eating.

The types of oral lesions are as follows:

• Reticular type
• Erosive type
• Ulcerative type
• Plaque type
• Atrophic type

The reticular type is the most common form and is usually not noticed by patients; it is found incidentally during a dental examination. It appears as lace-like white streaks inside the cheeks and does not cause pain. However, in erosive and ulcerative types, there are open sores, redness, and peeling inside the mouth. These patients feel extreme sensitivity to hot, acidic, spicy, and seasoned foods. Even brushing the teeth may become painful.

What Are the Symptoms of Lichen Planus in the Genital Area?

This is one of the conditions our patients are most hesitant to talk about, but it affects quality of life most deeply. Genital involvement can be seen in both women and men. In men, ring-shaped lesions are generally observed on the glans penis. In women, it presents as redness, white spots, or open sores at the vulva and vaginal entrance.

The problems caused by genital area involvement are as follows:

• Burning sensation
• Severe itching
• Pain during sexual intercourse
• Vaginal discharge
• Anatomical distortion
• Adhesions

Untreated genital lichen planus can over time cause tissue loss and anatomical adhesions (synechiae). The vaginal opening may narrow or the labia minora may stick together. Since this can lead to permanent functional problems, patients with complaints of burning, stinging, or non-healing sores in the genital area must consult a dermatologist without delay.

How Are Hair and Nail Lichen Planus Recognized?

The disease can also target skin appendages such as hair and nails. We call the form seen on the scalp “Lichen Planopilaris.” This is a condition that progresses insidiously and can lead to irreversible hair loss. It begins with mild redness and scaling around the hair follicles. The patient may think this is simple dandruff or eczema. However, when the inflammation destroys the hair follicle, hair never grows there again; we call this “cicatricial alopecia,” that is, scarring baldness.

“Frontal fibrosing alopecia” is considered a type of lichen planopilaris that affects the front hairline, forehead, and eyebrows.

In nail involvement, deterioration occurs in the nail structure. The nails become thinner, longitudinal lines form on them, and the nail plate appears as if it has been sanded.

The specific findings seen in the nails are as follows:

• Thinning of the nail
• Longitudinal ridging
• Nail separation
• Pterygium formation
• Nail loss

Pterygium is the condition in which the cuticle advances over the nail and splits it into two; this is a very characteristic finding for lichen planus.

By Which Methods Is Lichen Planus Diagnosed?

Generally, an experienced dermatologist can make the diagnosis by looking at the typical appearance of the lesions. Seeing those white reticular structures we call “Wickham striae” with the naked eye or with the handheld microscope called a dermoscope strengthens the diagnosis. However, in some cases, especially in atypical appearances or oral lesions, it is necessary to confirm the diagnosis.

The methods used for diagnosis are as follows:

• Clinical examination
• Dermoscopy examination
• Skin biopsy
• Blood tests
• Patch test

In the biopsy procedure, a small 3-4 millimeter sample is taken from the lesional area and examined by pathologists. When a “saw-tooth” appearance in the epidermis and damage in the basal layer are seen under the microscope, the diagnosis is confirmed. In addition, blood tests are requested to check the patient’s general health status and to investigate accompanying diseases such as Hepatitis C or thyroid problems.

Which Creams and Methods Are Used in Treatment?

The aim in the treatment of lichen planus is to stop itching, heal the lesions, and prevent scarring. We apply a stepwise treatment plan according to the severity of the disease and the affected area. While local treatments (creams) are usually sufficient in mild cases, systemic treatments (pills, injections) are used in widespread and resistant cases.

The agents used in topical treatment (applied medications) are as follows:

• Strong corticosteroids
• Calcineurin inhibitors
• Moisturizers
• Keratolytics
• Barrier creams

Cortisone creams are the cornerstone of treatment. Our patients may sometimes be hesitant about cortisone, but when used for the correct duration and at the correct dose, it is the most effective weapon for extinguishing inflammation in the skin. In areas where the skin is thin, such as the face and genital area, we prefer creams containing calcineurin inhibitors (tacrolimus, pimecrolimus) to avoid the side effects of cortisone.

When Are Systemic Treatments and Light Therapy Necessary?

If the disease has spread throughout the body, cannot be controlled with creams, or seriously impairs the patient’s quality of life, oral medications or light therapies come into play.

Advanced treatment options are as follows:

• Systemic steroids
• Acitretin
• Phototherapy
• Methotrexate
• Cyclosporine
• Hydroxychloroquine
• Mycophenolate mofetil

Phototherapy (light therapy) is especially effective in patients with widespread itching. Patients come to the hospital on certain days and are exposed to ultraviolet light in special cabins. This light suppresses the immune cells in the skin and reduces itching and rashes. Vitamin A derivatives such as acitretin are especially useful in thickened lesions on the hands and feet. In scalp lichen planus, drugs such as hydroxychloroquine are frequently used to stop hair loss. In very severe and rapidly progressing cases, short-term high-dose cortisone pills or injections can be life-saving.

Does Lichen Planus Turn Into Cancer?

This question is one of the issues that occupies our patients’ minds the most. The risk of the classic cutaneous form of lichen planus turning into cancer is almost negligible. However, the situation is slightly different in mucosal involvement. Especially in erosive oral lichen planus lesions that continue for many years and do not heal, there is a very low risk (between 1-3%) of developing squamous cell carcinoma:

The groups at risk are as follows:

• Patients with erosive oral lichen planus
• Smokers
• Alcohol users
• Those with poor oral hygiene
• Patients with hypertrophic lichen planus
• Those with long-term vulvar lichen planus

For this reason, patients with oral or genital involvement should go for a dermatology examination at least once or twice a year, even if their complaints disappear. When a non-healing, hardened, or bleeding sore is noticed, it should be checked immediately by taking a biopsy.

What Should Patients Pay Attention to in Daily Life?

Treatment does not end only with the prescription written by the doctor. The changes the patient makes in daily life directly affect the success of treatment. First of all, the itch-scratch cycle must be broken. The more one scratches, the more the disease spreads; the more it spreads, the more one scratches.

The points to pay attention to are as follows:

• Avoid scratching
• Keep nails short
• Use soft loofahs
• Stay away from hot water
• Use moisturizer
• Manage stress
• Quit smoking
• Use a soft toothbrush

Patients with oral lichen planus should avoid very hot, very sour, spicy, and heavily seasoned foods. In choosing toothpaste, products that do not irritate the inside of the mouth and do not contain sodium lauryl sulfate should be preferred. In addition, cleaning dental tartar and treating cavities positively affect the course of the disease, as they reduce inflammation inside the mouth.

What Is the Course of the Disease and How Long Does the Healing Process Take?

Lichen planus is a chronic disease, which means it is not realistic to expect it to disappear from one day to the next. Skin lesions usually tend to heal within 1-2 years with treatment or on their own. However, after healing, they may leave brown spots behind. These spots are not permanent damage; they are only a reaction of the skin to inflammation and will fade over time (this may take months).

Oral and genital area involvement, unfortunately, tends to be more stubborn and may last for years. During this process, it is normal to see flare-ups and remissions. What is important is to stay away from the factors that trigger the disease and not to miss regular follow-ups. Lichen planus is a manageable condition, and with the right approach, our patients can lead a healthy and comfortable life.