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Lichen Planus
Uday Khopkar, Ameet Valia
CHAPTER 1:
Pathogenesis of Lichen Planus
INTRODUCTION
ETIOLOGICAL FACTORS
Genetic Predisposition
Infections
Hepatitis C Virus Infection
Other Virus Infections
Candidal Infection
Vaccination
Drugs and Chemicals
Mechanical Trauma
Physical Factors
Oxidative Stress
Psychological Stress
Autoimmunity
IMMUNOPATHOGENESIS
LP-Specific Antigen Recognition
Cytotoxic T Cell Activation
Role of NK Cells
Role of Langerhans Cells
Activation of the Th1 Cytokine Response
Role of Keratinocytes
Keratinocyte Apoptosis
Other Mechanisms Possibly Operative in the Pathogenesis of LP
Immunopathogenesis of OLP
Oral Lichenoid Reaction due to Amalgam
CONCLUSION
CHAPTER 2:
Autoimmune and Other Associations of Lichen Planus
INTRODUCTION
AUTOIMMUNE ASSOCIATIONS
HCV Infection, Primary Biliary Cirrhosis, Chronic Active Hepatitis and Lichen Planus
Thymoma and Lichen Planus56
Autoimmune Thyroid Disease and Lichen Planus
Multiple Autoimmune Diseases and Lichen Planus
Vitiligo, Psoriasis and Lichen Planus
Erosive Lichen Planus of the Vulva and Autoimmune Disease
Paraneoplastic Pemphigus and Lichen Planus
OTHER ASSOCIATIONS
Dyslipidemia and Lichen Planus
Stress and Lichen Planus
CONCLUSION
CHAPTER 3:
Clinical Features of Lichen Planus
TERMINOLOGY
HISTORICAL ASPECTS
EPIDEMIOLOGY
Patient Profile
Age
Sex
Seasonal Variation
Familial Predilection
CLINICAL PRESENTATIONS
Primary Lesion
Acute Generalized (Guttate or Eruptive) Pattern
Acute and Subacute Pattern with Confluence of Lesions
Chronic Localized Pattern
Koebner Phenomenon in Lichen Planus
VARIANTS OF LICHEN PLANUS
Configurational Variants
Annular Lichen Planus
Linear and Blaschkoid Lichen Planus
Morphologic Variants
Hypertrophic Lichen Planus
Atrophic Lichen Planus
Erosive or Ulcerative Lichen Planus
Vesicular Lichen Planus
Follicular Lichen Planus
Micropapular or Miliary Lichen Planus
Lichen Planus Pigmentosus
Perforating Lichen Planus
Distributional Variants
Actinic Lichen Planus (Tropical Lichen Planus)
Lichen Planus at Special Sites
Scalp
Mucosae
Oral Lichen Planus
Female Genital Lichen Planus
Male Genital Lichen Planus
Inverse Lichen Planus
Nail Lichen Planus
Palmoplantar Lichen Planus
Infrequent Variants
Lupus Erythematosus-Lichen Planus Overlap
Lichen Planus Pemphigoides
Invisible Lichen Planus
Erythrodermic Lichen Planus
Post-inflammatory Effects
CHAPTER 4:
Lichen Planus in Children
INTRODUCTION
EPIDEMIOLOGY
PATHOGENESIS
CLINICAL FEATURES
DIAGNOSIS
TREATMENT
CHAPTER 5:
Lichen Planus Pigmentosus
INTRODUCTION
ETIOLOGY AND PATHOGENESIS
CLINICAL FEATURES
HISTOPATHOLOGY
DIFFERENTIAL DIAGNOSIS
PROGNOSIS AND TREATMENT
CHAPTER 6:
Lichen Planopilaris
INTRODUCTION
ETIOLOGY AND PATHOGENESIS
CLINICAL FEATURES
Classic Lichen Planopilaris
Graham-Little-Piccardi-Lassueur Syndrome
Frontal Fibrosing Alopecia
DIAGNOSIS
Dermoscopy
Histopathology
Confocal Microscopy
DIFFERENTIAL DIAGNOSIS
MANAGEMENT
Lichen Planopilaris Activity Index
Treatment
Frontal Fibrosing Alopecia
CONCLUSION
CHAPTER 7:
Lichen Planus Pemphigoides
INTRODUCTION
PATHOGENESIS
CLINICAL FEATURES
HISTOPATHOLOGY
IMMUNOFLUORESCENCE
DIFFERENTIAL DIAGNOSIS
PROGNOSIS AND MANAGEMENT
CHAPTER 8:
Palmoplantar Lichen Planus
INTRODUCTION
CLINICAL VARIANTS
Hypertrophic PPLP
PPLP with Punctate Keratotic Papules
Diffuse Keratoderma
Erythematous Scaly Variant
PPLP with Vesicle like Papules
Vesicular PPLP
Erosive and Ulcerative Variant
Psoriasiform or Eczematous Variant
Hyperpigmented Macules
Plaques with Collarette Scale
PPLP with Violaceous Papules
Hyperkeratotic Plaques with Pits
PPLP with Umbilicated Papules
DIAGNOSIS
Histopathology
MALIGNANT CHANGE IN PPLP
TREATMENT
CONCLUSION
CHAPTER 9:
Nail Lichen Planus
INTRODUCTION
EPIDEMIOLOGY
CLINICAL PRESENTATION
Matricial Lesions and Nail Plate Changes
Nail Bed Involvement with Nail Plate Changes
HISTOPATHOLOGICAL FEATURES
DIFFERENTIAL DIAGNOSIS
Nail Psoriasis
Trachyonychia (Twenty Nail Dystrophy)
Yellow Nail Syndrome
Bowen's Disease of the Nail Bed
Pterygium
TREATMENT
CHAPTER 10:
Oral Lichen Planus
INTRODUCTION
ETIOLOGY
Trauma
Infections
Stress
Genetics
Foods
PATHOGENESIS
Autoimmunity
Role of APC and CD4+ T cells
Role of CD8+ T cells
Keratinocyte Apoptosis by CD8+ Cells
Role of the Epidermal Basement Membrane
Lymphocyte Homing Mechanism
Other Mediators of Inflammation
Matrix Metalloproteinases
Mast Cells
Chemokines
CLINICAL FEATURES
Scoring System for Oral Lichen Planus
WORK UP
Histopathology
Immunofluorescence
TREATMENT
Corticosteroids
Antifungal Agents
Calcineurin Inhibitors
Retinoids
Immunosuppressants and Immunomodulators
Cyclosporine
Azathioprine
Mycophenolate Mofetil
Dapsone
Antimalarials
Levamisole
Interferons
Biologicals
Antibiotics
Miscellaneous
Physical Treatment Modalities
Mouth PUVA
UVB Phototherapy
Photodynamic Therapy
Laser Therapy
Surgery
CHAPTER 11:
Vulvar Lichen Planus
INTRODUCTION
CLINICAL FEATURES
Erosive
White Reticulate Pattern
Papulosquamous
Hypertrophic
DIAGNOSIS
Histopathology
DIFFERENTIAL DIAGNOSIS
PROGNOSIS
THERAPY
CHAPTER 12:
Histopathology of Lichen Planus and its Variants
INTRODUCTION
INDICATIONS FOR A SKIN OR MUCOSAL BIOPSY IN LICHEN PLANUS
HISTOPATHOLOGY OF LICHEN PLANUS
Classic Lichen Planus3–7
Eruptive Lichen Planus3
Micropapular Lichen Planus
Vesicular Lichen Planus3
Actinic Lichen Planus3,5
Atrophic Lichen Planus3
Hypertrophic Lichen Planus3-5,9
Erosive or Ulcerative Lichen Planus
Lichen Planopilaris3,4,10
Lichen Planus Pigmentosus11
Oral Lichen Planus3–5
Genital Lichen Planus3,12
Nail Lichen Planus13
Palmoplantar Lichen Planus14
Lichen Planus Pemphigoides4,8
Post-inflammatory Hyperpigmentation Following Lichen Planus
HISTOPATHOLOGIC DIFFERENTIAL DIAGNOSIS OF LICHEN PLANUS
Lichenoid Drug Eruption3,4
Lichenoid Keratosis4
Lichen Planus-Lupus Erythematosus (LE-LP) Overlap3,5,14,15
Lichenoid Contact Dermatitis3
Pityriasis Lichenoides Chronica3
Lichen Nitidus4
Lichen Striatus4
Lichen Sclerosus Et Atrophicus
Lichenoid Purpura
Mycosis Fungoides4
Graft versus Host Disease (GVHD)4
IMMUNOHISTOCHEMISTRY IN LICHEN PLANUS
SPECIAL STAINS IN LICHEN PLANUS17,18
INDIRECT IMMUNOFLUORESCENCE IN LICHEN PLANUS19
CLINICOPATHOLOGIC CORRELATION
CONCLUSION
CHAPTER 13:
Dermoscopy of Lichen Planus
INTRODUCTION
DERMOSCOPIC SIGNS IN LICHEN PLANUS
Patterns Seen In an Active Lesion
Under Polarized Light
Under Normal Light
Patterns Seen In a Subsiding Lesion
Under Polarized Light
HISTOPATHOLOGICAL CORRELATION
Vascular Structures
Nonvascular Structures
DERMOSCOPY OF VARIANTS OF LICHEN PLANUS
Hypertrophic Lichen Planus
ALichen Planopilaris
Lichen Planus Pigmentosus
DERMOSCOPIC DIFFERENTIAL DIAGNOSIS OF LICHEN PLANUS
Chronic Plaque Psoriasis
Lichenoid Drug Eruption
Lichen Nitidus
CONCLUSION
CHAPTER 14:
Lichen Planus: Differential Diagnosis
INTRODUCTION
ERUPTIVE LICHEN PLANUS
ANNULAR LICHEN PLANUS
ACTINIC LICHEN PLANUS
ATROPHIC LICHEN PLANUS
HYPERTROPHIC LICHEN PLANUS
PALMOPLANTAR LICHEN PLANUS
LINEAR LICHEN PLANUS
LICHEN PLANOPILARIS
ORAL LICHEN PLANUS
GENITAL LICHEN PLANUS
LICHEN PLANUS PIGMENTOSUS
NAIL LICHEN PLANUS
BULLOUS LICHEN PLANUS
CONCLUSION
CHAPTER 15:
Lichenoid Drug Eruptions
INTRODUCTION
EPIDEMIOLOGY
PATHOGENESIS
CLINICAL FEATURES
Drugs Causing Lichenoid Drug Eruptions
HISTOPATHOLOGY
DIAGNOSIS
TREATMENT
CHAPTER 16:
Lichen Planus and Malignancy
INTRODUCTION
MALIGNANT TRANSFORMATION OF CUTANEOUS LICHEN PLANUS
Cutaneous Lichen Planus to Squamous Cell Carcinoma
Cutaneous Lichen Planus to Basal Cell Carcinoma
MALIGNANT TRANSFORMATION OF ORAL LICHEN PLANUS
Lichenoid Dysplasia and Oral Lichen Planus
Is Oral Lichen Planus Intrinsically Precancerous?
Criteria of Premalignancy in Oral Lichen Planus
Role of External Cofactors
Identification of Patients with Oral Lichen Planus at Risk of Malignant Transformation
Risk Attenuation of Oral Squamous Cell Carcinoma in Oral Lichen Planus
LICHEN PLANUS AS A PARANEOPLASTIC DISORDER
IMMUNOPATHOGENESIS OF MALIGNANT TRANSFORMATION OF ORAL AND CUTANEOUS LICHEN PLANUS
LICHEN PLANUS/ORAL LICHEN PLANUS AND GRAFT VS HOST DISEASE (GVHD): IMPLICATIONS FOR IMMUNOPATHOGENESIS
CONCLUSION
CHAPTER 17:
Local Therapy of Lichen Planus
INTRODUCTION
LOCAL THERAPY OF CUTANEOUS LICHEN PLANUS
Antipruritic Agents
Topical Corticosteroids
Topical Calcineurin Inhibitors
Other Agents
TOPICAL THERAPY OF MUCOSAL LICHEN PLANUS
Symptomatic Treatments
Corticosteroids
Calcineurin Inhibitors
Miscellaneous Agents
INTRALESIONAL CORTICOSTEROID INJECTIONS
INTRALESIONAL IMMUNOTHERAPY
CONCLUSION
CHAPTER 18:
Systemic Treatment of Lichen Planus
INTRODUCTION
DRUGS USED FOR CUTANEOUS LICHEN PLANUS
Retinoids
Photochemotherapy and Phototherapy
Corticosteroids
Choosing the Appropriate Corticosteroid18,19
Conventional Daily Therapy
Pulse Therapy
Safety, Efficacy and Relapse
Enoxaparin Sodium (Low-Molecular-Weight Heparin)
Immunosuppressives
Cyclosporine1–4
Mycophenolate Mofetil1–4
Azathioprine1–4
Methotrexate
Biologicals1–4
Miscellaneous Therapies
Dapsone38–41
Hydroxychloroquine Sulfate1–4
Metronidazole
Sulfasalazine
Curcumin
Apremilast
TYPE SPECIFIC TREATMENT PLANS
Generalized Lichen Planus
Localized Lichen Planus
Hypertrophic Lichen Planus
Lichen Planus Actinicus
Lichen Planus Pigmentosus
Erythema Dyschromicum Perstans
Follicular and/or Nail Lichen Planus
SUMMARY
CHAPTER 19:
Light Therapy in Lichen Planus
INTRODUCTION
MECHANISM OF ACTION OF PHOTOTHERAPY
CUTANEOUS LICHEN PLANUS
Psoralen with UVA (PUVA) Therapy
NB-UVB Therapy
UVA1 Therap
ORAL LICHEN PLANUS
CONCLUSION
INDEX
TOC
Index
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