Atrophic Lichen Planus

Mary Tonsager; Charles E. Crutchfield, III

Disclosures

Dermatology Nursing. 2004;16(1) 

The "Clinical Snapshot" series provides a concise examination of a clinical presentation including history, treatment, patient education, and nursing measures. Using the format here, you are invited to submit your "Clinical Snapshot" to Dermatology Nursing.

History: This 43-year-old male presented with a pruritic patch on the glans penis (see Figure 1). He described a tingling sensation, then pruritus that preceded the appearance of the lesions. The lesions were present for 7 months.

Figure 1.

Lichen Planus: Penis

Description: Small violaceous flat-topped macules.

Location: This eruption was on the glans penis. The lesions of lichen planus can occur anywhere on the body but favor the flexor wrists, trunk, medial thighs, shins, dorsal hands, and lower back. The oral mucosa is frequently affected and these eruptions are much more chronic, and can lead to an oral squamous cell carcinoma if not followed carefully. Additional involvements include the fingernails (producing a fingernail dystrophy) and scalp (producing a scarring alopecia). In the rare and atypical atrophic variant, the normal papules are replaced by flat violaceous macules that are found in the axillae and glans penis.

Etiology: Lichen planus is a common, pruritic, inflammatory disease of the skin, hair follicles, and mucous membranes. The cause of lichen planus is unknown; however, some lichenoid rashes are associated with allergic reactions to medications. Exposure to gold (commonly found in popular alcoholic schnapps liquors) and the metals found in photographic film development and processing have also caused a lichen planus-type eruption. A lichenoid drug reaction should be suspected if the eruption is photodistributed and widespread. Additionally, lichen planus has recently been associated with hepatitis C and all patients presented with lichen planus should be given a hepatitis screen.

Hallmark of the Disease: Pinpoint papules expand to form small violaceous flat-topped polygonal papules with sudden onset. As in this case, the atrophic sub-type presents as flat macules and patches. There is also a thick hypertrophic variant that is commonly found on the shins/lower extremities. Lichen planus also will tend to form on areas of skin injury/trauma. This is known as the isomorphic response or Koebner phenomena. Varients of lichen planus are presented in Figures 2-9.

Figure 2.

Lichen Planus: Scalp

Figure 3.

Lichen Planus: Axilla

Figure 4.

Lichen Planus: Oral Ulceration

Figure 5.

Lichen Planus: Ankle

Figure 6.

Lichen Planus: Fingernail

Figure 7.

Lichen Planus: Forearms

Figure 8.

Lichen Planus: Hypertrophic

Figure 9.

Lichen Planus: Koebner

Treatment: There is no cure for lichen planus but treatment often relieves itching and improves the appearance. Topical corticosteroid creams are effective. In more severe and widespread cases, lesions respond well to systemic corticosteroids or intralesional steroid injections. Phototherapeutic measures may also be employed successfully in recalcitrant and/or severely symptomatic cases. In this case, a topical nonsteroidal anti-inflammatory ointment (tacrolimus) was used twice daily with great success.

Normal Course: Two-thirds of patients with skin lesions will have lichen planus for 1 to 2 years with spontaneous clearing in the second year. One in five will have a recurrence of lichen planus. Oral lichen planus with ulceration must be followed meticulously to prevent the development of oral squamous cell carcinoma. In these cases it is imperative that alcohol consumption and tobacco products be avoided because they have both been associated with the increased risk of oral squamous cell carcinoma in ulcerative lichen planus.

Patient Education: Reassure patients that lichen planus is not contagious and treatment is often effective in relieving itching and improving the appearance of the rash until it goes away.

Nursing Measures: Obtain a complete medication history because lichen planus-like eruptions may occur as an allergic reaction to medication for high blood pressure, heart disease, and arthritis. Additionally, the history should include chemical exposure, blood transfusions, IV drug use, and gold-containing adult beverages. Advise patient to minimize injury to skin as new lesions may form in damaged skin. Most importantly, advise patients to contact their dermatology health care professional if sores develop in the mouth.

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