Offering an Off-Label Therapeutic Algorithm for Lichen Planus

Lichen planus (LP) is a poorly characterized, chronic inflammatory dermatosis notable for violaceous to brown/ black polygonal pruritic papules and plaques, often with lacey scale, and reticular white erosions involving mucosal sites. LP affects approximately 1-2% of the population,¹ with oral lichen planus (OLP) occurring more frequently and a greater treatment challenge than the genital or cutaneous variants.² A population based study found patients with OLP were 4.8 times more likely to develop oral squamous cell carcinoma (OSCC) than matched controls.3 Ten to 15% of patients with LP concurrently have nail lichen planus (NLP).⁴ LP and OLP have been associated with sleep disturbances, anxiety, depression as well as a 37% increased risk for cardiovascular disease (CVD).^5,6 Remarkably, no current therapy is FDA approved for LP. This review provides an updated algorithm for treating LP, OLP, and NLP utilizing recent reports and summarizes the latest evidence for off-label therapeutic options (Figure1). Topical corticosteroids (TCS) are the mainstay of treatment for all variants of LP.⁷

Topical calcineurin inhibitors (TCI), tacrolimus and pimecrolimus, are useful steroid sparing agents, and during scheduled breaks from TCS.^8,9 Magic mouthwash has shown a favorable effect for erosive lesions.¹⁰ Magic mouthwash is usually a mixture of diphenhydramine, lidocaine, magnesium hydroxide/aluminum hydroxide, nystatin and corticosteroids.¹¹ For recalcitrant OLP, patients can swish-and-spit crushed and dissolved tacrolimus (1mg/500mL) or cyclosporine pills (500mg per 5mL).^12,13