Editing Lichen planus

{{Short description|Human chronic inflammatory disease}}
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| field           = [[Dermatology]]
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| synonyms        = LP
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'''Lichen planus''' ('''LP''') is a chronic inflammatory and [[autoimmune disease]] that affects the skin, nails, hair, and mucous membranes.<ref name="Wang">{{cite journal |vauthors=Wang EH, Monga I, Sallee BN, Chen JC, Abdelaziz AR, Perez-Lorenzo R, Bordone LA, Christiano AM| title=Primary cicatricial alopecias are characterized by dysregulation of shared gene expression pathways |journal=PNAS Nexus |volume=1 |issue=3 |pages=pgac111 |date=Jul 2022 |pmid=35899069 |doi=10.1093/pnasnexus/pgac111| pmc=9308563 }}</ref><ref name=":1">{{cite journal |vauthors=Gorouhi F, Davari P, Fazel N |title=Cutaneous and mucosal lichen planus: a comprehensive review of clinical subtypes, risk factors, diagnosis, and prognosis |journal=The Scientific World Journal |volume=2014 |pages=742826 |date=2014-01-30 |pmid=24672362 |pmc=3929580 |doi=10.1155/2014/742826 |doi-access=free}}</ref> It is not an actual [[lichen]], but is named for its appearance.<ref name="TG2009" /> It is characterized by polygonal, flat-topped, violaceous papules and plaques with overlying, reticulated, fine white scale ([[Wickham striae|Wickham's striae]]), commonly affecting dorsal hands, flexural wrists and forearms, trunk, anterior lower legs and oral mucosa.<ref>{{Cite journal|date=2005-03-01|title=Inverse lichen planus: An unusual morphologic variant of a classic papulosquamous dermatosis |url=https://www.jaad.org/article/S0190-9622(04)03040-3/abstract |journal=Journal of the American Academy of Dermatology|volume=52|issue=3|pages=P64 |doi=10.1016/j.jaad.2004.10.268|issn=1097-6787|doi-access=free|url-access=subscription}}</ref> The hue may be gray-brown in people with darker skin.<ref name=Li2021>{{cite book |last1=Onalaja |first1=Amanda A. |last2=Taylor |first2=Susan C. |editor1-last=Li |editor1-first=Becky S. |editor2-last=Maibach |editor2-first=Howard I. |title=Ethnic Skin and Hair and Other Cultural Considerations |date=2021 |publisher=Springer |location=Switzerland |isbn=978-3-030-64829-9 |chapter-url=https://books.google.com/books?id=_m4hEAAAQBAJ&dq=planus&pg=PA10 |language=en |chapter=1. Defining skin color|page=10}}</ref> Although there is a broad clinical range of LP manifestations, the skin and oral cavity remain as the major sites of involvement.<ref>{{Cite journal |author1=Meredith A. Olson |author2=Roy S. Rogers III |author3=Alison J. Bruce|date=2016|title=Oral lichen planus|journal=Clinics in Dermatology}}</ref> The cause is unknown, but it is thought to be the result of an [[autoimmune]] process with an unknown initial trigger. There is no cure, but many different medications and procedures have been used in efforts to control the symptoms.

The term [[lichenoid reaction]] ([[lichenoid eruption]] or lichenoid lesion) refers to a [[lesion]] of similar or identical [[histopathology|histopathologic]] and [[Clinical research|clinical]] appearance to lichen planus (i.e., an area which resembles lichen planus, both to the naked eye and under a [[microscope]]).<ref name=Greenberg2008>{{cite book|vauthors=Greenberg MS, Glick M, Ship JA |title=Burket's oral medicine|year=2008|publisher=BC Decker|location=Hamilton, Ont.|isbn=9781550093452|pages=89–97|url=https://books.google.com/books?id=Q2SP8cOZPvkC&pg=PA89 |edition=11th}}</ref><ref name=Lewis2012>{{cite book|vauthors=Lewis MA, Jordan RC |title=Oral medicine|year=2012|publisher=Manson Publishing|location=London|isbn=9781840761818|pages=66–72|url=https://books.google.com/books?id=_2uLqxLsg5IC&pg=PA70 |edition=2nd}}</ref> Sometimes dental materials or certain medications can cause lichenoid reactions.<ref name=Greenberg2008 /> They can also occur in association with [[graft versus host disease]].<ref name=Greenberg2008 /><ref name=Barnes2009>{{cite book|veditors=Barnes L |title=Surgical pathology of the head and neck|year=2009|publisher=Informa healthcare|location=New York|isbn=9781420091632|edition=3rd}}</ref>{{rp|258}}
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==Classification==

''Lichen planus'' lesions are so called because of their "[[lichen]]-like" appearance<ref name="TG2009">{{Cite book |title=Therapeutic guidelines |publisher=Therapeutic Guidelines |year=2009 |isbn=978-0-9804764-3-9 |edition=Version 3. |location=North Melbourne, Vic. |pages=254–55, 302}}</ref> and can be classified by the site they involve, or by their morphology.

===Site===
Lichen planus may be categorized as affecting [[mucous membrane|mucosal]] or [[skin|cutaneous]] surfaces.
* ''Cutaneous'' forms are those affecting the skin, scalp, and nails.<ref name="Le Cleach 2012">{{cite journal | vauthors = Le Cleach L, Chosidow O | title = Clinical practice. Lichen planus | journal = The New England Journal of Medicine | volume = 366 | issue = 8 | pages = 723–32 | date = February 2012 | pmid = 22356325 | doi = 10.1056/NEJMcp1103641 }}</ref><ref name="Asch 2011">{{cite journal | vauthors = Asch S, Goldenberg G | title = Systemic treatment of cutaneous lichen planus: an update | journal = Cutis | volume = 87 | issue = 3 | pages = 129–34 | date = March 2011 | pmid = 21488570 }}</ref><ref name="Sharma 2012">{{cite journal | vauthors = Sharma A, Białynicki-Birula R, Schwartz RA, Janniger CK | title = Lichen planus: an update and review | journal = Cutis | volume = 90 | issue = 1 | pages = 17–23 | date = July 2012 | pmid = 22908728 }}</ref>
* ''Mucosal'' forms are those affecting the lining of the [[gastrointestinal tract]] (mouth, pharynx, esophagus, stomach, anus), [[larynx]], and other mucosal surfaces including the genitals, [[peritoneum]], ears, nose, bladder and [[conjunctiva]] of the eyes.<ref name="Cheng 2012">{{cite journal | vauthors = Cheng S, Kirtschig G, Cooper S, Thornhill M, Leonardi-Bee J, Murphy R | title = Interventions for erosive lichen planus affecting mucosal sites | journal = The Cochrane Database of Systematic Reviews | volume = 2 | issue = 2 | pages = CD008092 | date = February 2012 | pmid = 22336835 | doi = 10.1002/14651858.CD008092.pub2 | pmc = 10794897 | url = http://dare.ubvu.vu.nl/bitstream/1871/48562/1/302053.pdf | hdl = 1871/48562 }}</ref><ref name=YAMADA2009 /><ref name="Bruch 2010">{{cite book|vauthors=Treister NS, Bruch JM |title=Clinical oral medicine and pathology|url=https://archive.org/details/clinicaloralmedi00bruc |url-access=limited |year=2010|publisher=Humana Press|location=New York|isbn=978-1-60327-519-4|pages=[https://archive.org/details/clinicaloralmedi00bruc/page/n69 59]–62}}</ref>

===Pattern===
Lichen planus lesions can occur in many different forms or [[Morphology (biology)|morphologies]]:<ref name="Clinical variants of lichen planus">{{cite journal | vauthors = Wagner G, Rose C, Sachse MM | title = Clinical variants of lichen planus | journal = Journal der Deutschen Dermatologischen Gesellschaft | volume = 11 | issue = 4 | pages = 309–19 | date = April 2013 | pmid = 23320493 | doi = 10.1111/ddg.12031 | s2cid = 8927462 | doi-access =  }}</ref>

;Papular
:Papular form is the classic cutaneous lichen planus (CLP) lesion characterized by shiny, red or purple-colored, flat-topped papule. Lesions may have a thin, transparent, and adherent scale. Fine whitish points or lacy lines (Wickham's striae) may be seen on the surface of well-developed papules.<ref name=":1" />
;Annular
:'Ring-shaped' lesions that develop gradually from single small pigmented spots into circular groups of papules with clear, unaffected skin in the center. The ring-like lesions may very slowly enlarge, co-join and morph into larger irregular (serpentine) bands, sometimes accompanied by lines (See Linear, below). Annular CLP is uncommon and classically involves the male genitalia (glans penis and penile shaft), groin, axilla and also the extremities.<ref name=":1" />
;Linear
: Papules are arranged in a line (the "Blaschko line").<ref>{{Citation |last1=Arnold |first1=David L. |title=Lichen Planus |date=2024 |work=StatPearls |url=https://www.ncbi.nlm.nih.gov/books/NBK526126/ |access-date=2024-10-23 |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=30252382 |last2=Krishnamurthy |first2=Karthik}}</ref> This pattern may develop secondary to trauma ([[Koebner phenomenon|koebnerization]]) or, uncommonly, as a spontaneous, isolated eruption, usually on the extremities, and rarely on the face.<ref name=BOLOGNIA2008>{{cite book |editor1-last=Bolognia |editor1-first=Jean L. |title=Dermatology |year=2008 |publisher=Mosby/Elsevier |location=St. Louis |isbn=978-1-4160-2999-1 |edition=2nd |editor2-first=Joseph L. |editor2-last=Jorizzo |editor3-first=Ronald P. |editor3-last=Rapini}}</ref>
; Hypertrophic
: This pattern is characterized by hyperkeratotic thick pruritic red-brown to purple-gray plaques with follicular accentuation. Hypertrophic CLP commonly involves the extremities, especially the interphalangeal joints and the anterior legs in a symmetrical distribution.<ref name=":1" /> This form is also known as "lichen planus verrucosus".
; Atrophic
: This morphology is characterized by the presence of a few well-demarcated, white-bluish [[papule]]s or plaques with central superficial atrophy. Atrophic CLP is the clinical endpoint of chronic annular or hypertrophic LP with atrophic lesions. The use of potent topical corticosteroids for a long-term may predispose the patient to developing atrophic lesions.<ref name=":1" />
; Bullous
: This morphology is characterized by the development of vesicles and bullae with the skin lesions. This is a rare variant of lichen planus, and also known as "vesiculobullous lichen planus".
; Actinic
: Rare form presenting as nummular patches or plaques with a hypopigmented halo surrounding a hyperpigmented center. Actinic CLP is more prevalent in African Americans, Indians, and Middle-Eastern individuals and commonly affects the sun-exposed areas.<ref name=":1" />
; Ulcerative
: This morphology is characterized by chronic, painful bullae and ulceration of the feet, often with [[cicatricial alopecia|cicatricial]] sequelae evident. This is a rare variant of lichen planus.
; Pigmented 
: This morphology is characterized by hyperpigmented, dark-brown [[macule]]s in sun-exposed areas and flexural folds. This is a rare variant of lichen planus.
; Follicular
: Characterized by follicular, flat, elevated or hemispherical erythematous papules with or without keratoses presenting in groups or disseminated. The [[Graham-Little syndrome|Graham‐Little‐Piccardi‐Lasseur syndrome]], seen in a familial pattern and also predominantly in women, is characterized by the appearance of follicular LP on the trunk with LP follicularis decalvans on the scalp. Follicular LP on the scalp is more likely to lead to scarring alopecia.<ref name="Clinical variants of lichen planus"/>
; Inverse
: Characterized by extensive erythematous lesions with poorly defined borders and in part with lichenification. Inverse LP typically affects the axillae, inguinal creases, limb flexures and submammary region. Pigmentation of the individual lesions at these inverse locations are typical. Additionally, keratotic papules and erosions with a bizarre configuration can occur.<ref name="Clinical variants of lichen planus"/>

===Overlap syndromes===
Occasionally, lichen planus is known to occur with other conditions. For example:
* [[Lupus erythematosus]] overlap syndrome. Lesions of this syndrome share features of both lupus erythematosus and lichen planus. Lesions are usually large and hypopigmented, atrophic, and with a red to blue colour and minimal scaling. [[Telangectasia]] may be present.<ref name="ANDREWS2006pp219-24">{{cite book|title=Andrews' Diseases of the skin : clinical dermatology|url=https://archive.org/details/andrewsdiseasess00mdwi|url-access=limited|last2=Elston|first2=Dirk M.|last3=Berger|first3=Timothy G. | name-list-style = vanc |publisher=Saunders/Elsevier|isbn=978-1-4377-0314-6|edition=11th|location=London|pages=[https://archive.org/details/andrewsdiseasess00mdwi/page/n227 219]–24|first1=William D.|last1=James|year=2011}}</ref><ref name=FITZPATRICK2003pp366_470-1>{{cite book |editor1-first=Irwin M. |editor1-last=Freedberg | name-list-style = vanc |title=Fitzpatrick's dermatology in general medicine |year=2003 |publisher=McGraw-Hill |location=New York, NY |isbn=978-0-07-138076-8 |pages=366, 470–71 |edition=6th}}</ref>
* [[Lichen sclerosus]] overlap syndrome, sharing features of lichen planus and lichen sclerosus.<ref name=ANDREWS2006p220>{{cite book |first1=William D. |last1=James |first2=Dirk M. |last2=Elston |first3=Timothy G. |last3=Berger | name-list-style = vanc |title=Andrews' Diseases of the skin : clinical dermatology |url=https://archive.org/details/andrewsdiseasess00mdwi |url-access=limited |publisher=Saunders/ Elsevier |location=London |isbn=978-1-4377-0314-6 |edition=11th |page=[https://archive.org/details/andrewsdiseasess00mdwi/page/n228 220]|year=2011 }}</ref>

==Signs and symptoms==
[[File:Lichen planus lip.jpg|thumb|right |Lichen planus affecting the lower lip]]

Although lichen planus can present with a variety of lesions, the most common presentation is as a well defined area of purple-coloured, itchy, flat-topped papules with interspersed lacy white lines (Wickham's striae). This description is known as the characteristic "6 Ps" of lichen planus: planar (flat-topped), purple, polygonal, pruritic, papules, and plaques.<ref name="Le Cleach 2012" /> This rash, after regressing, is likely to leave an area of hyperpigmentation that slowly fades. That said, a variety of other lesions can also occur.<ref name="TG2009" />

===Skin===
[[File:Lichen planus on leg.JPG|thumbnail|right|Cutaneous lichen planus on the shin]]
[[File:Lehman, 2009 Fig11.tiff|thumbnail|right|Pterygium formation in the nails caused by lichen planus]]
Variants of cutaneous lichen planus are distinguished based upon the appearance of the lesions and/or their distribution.<ref name=FITZPATRICK2003p466>{{cite book |editor1-first=Irwin M. |editor1-last=Freedberg | name-list-style = vanc |title=Fitzpatrick's dermatology in general medicine |year=2003 |publisher=McGraw-Hill |location=New York, NY |isbn=978-0-07-138076-8 |page=466 |edition=6th}}</ref> Lesions can affect the:
* Extremities (face, dorsal hands, arms, and nape of neck).{{efn|Cutaneous lichen planus affecting the extremities is also known as "lichen planus actinicus", "Actinic lichen niditus", "Lichen planus atrophicus annularis", "Lichen planus subtropicus", "Lichen planus tropicus", "Lichenoid melanodermatitis", and "Summertime actinic lichenoid eruption"}} This is more common in Middle Eastern countries in spring and summer, where sunlight appears to have a precipitating effect.<ref name=BOLOGNIA2008 /><ref name=FITZPATRICK2003p468>{{cite book |editor1-first=Irwin M. |editor1-last=Freedberg | name-list-style = vanc |title=Fitzpatrick's dermatology in general medicine |year=2003 |publisher=McGraw-Hill |location=New York, NY |isbn=978-0-07-138076-8 |page=468 |edition=6th}}</ref><ref name=ANDREWS2006p223>{{cite book |first1=William D. |last1=James |first2=Dirk M. |last2=Elston |first3=Timothy G. |last3=Berger |title=Andrews' Diseases of the skin : clinical dermatology |url=https://archive.org/details/andrewsdiseasess00mdwi |url-access=limited |publisher=Saunders/ Elsevier |location=London |isbn=978-1-4377-0314-6 |edition=11th |page=[https://archive.org/details/andrewsdiseasess00mdwi/page/n231 223]|year=2011 }}</ref>
* Palms and soles
* [[Intertriginous]] areas of the skin. This is also known as "inverse lichen planus".<ref name=BOLOGNIA2008 />
* Nails<ref name="Gordon 2011">{{cite journal | vauthors = Gordon KA, Vega JM, Tosti A | title = Trachyonychia: a comprehensive review | journal = Indian Journal of Dermatology, Venereology and Leprology | volume = 77 | issue = 6 | pages = 640–5 | date = Nov–Dec 2011 | pmid = 22016269 | doi = 10.4103/0378-6323.86470 | doi-access = free }}</ref> characterized by irregular longitudinal grooving and ridging of the nail plate, thinning of the nail plate, [[Pterygium unguis|pterygium]] formation, shedding of the nail plate with atrophy of the nail bed, subungual keratosis, longitudinal erthronychia (red streaks), and subungual hyperpigmentation.<ref name=ANDREWS2006p781>{{cite book |first1=William D. |last1=James |first2=Dirk M. |last2=Elston |first3=Timothy G. |last3=Berger | name-list-style = vanc |title=Andrews' Diseases of the skin : clinical dermatology |url=https://archive.org/details/andrewsdiseasess00mdwi |url-access=limited |publisher=Saunders/ Elsevier |location=London |isbn=978-1-4377-0314-6 |edition=11th |page=[https://archive.org/details/andrewsdiseasess00mdwi/page/n789 781]|year=2011 }}</ref> A [[Trachyonychia|sand-papered appearance]] is present in around 10% of individuals with nail lichen planus.<ref name="Gordon 2011" />
* Hair and scalp. The scalp is rarely affected by a condition known as lichen planopilaris, acuminatus, follicular lichen planus, and peripilaris, characterised by violaceous, adherent follicular scale with progressive scarring alopecia. While lichen planus and lichen planopilaris may occur together, aside from sharing the term 'lichen' and revealing inflammation on skin biopsy, there is neither established data on their co-occurrence nor data to suggest a common etiology. Lichen planopilaris is considered an orphan disease with no definitive prevalence data and no proven effective treatments.<ref name="Orphanet 2016">{{cite web|title=Orphanet: Rare Diseases|url=http://www.orpha.net/consor/cgi-bin/OC_Exp.php?Lng=GB&Expert=525|website=Orphanet|access-date=June 3, 2016}}</ref><ref name="Carfintl 2016">{{cite web|title=Cicatricial Alopecia Research Foundation|url=http://www.carfintl.org|website=www.carfintl.org|access-date=June 3, 2016}}</ref>
Other variants may include:
* ''Lichen planus pemphigoides'' characterized by the development of tense blisters atop lesions of lichen planus or the development vesicles de novo on uninvolved skin.<ref name=FITZPATRICK2003p471>{{cite book |editor1-first=Irwin M. |editor1-last=Freedberg | name-list-style = vanc |title=Fitzpatrick's dermatology in general medicine |year=2003 |publisher=McGraw-Hill |location=New York, NY |isbn=978-0-07-138076-8 |page=471 |edition=6th}}</ref>
* ''Keratosis lichenoides chronica'' (also known as "Nekam's disease") is a rare dermatosis characterized by violaceous papular and nodular lesions, often arranged in a linear or reticulate pattern on the dorsal hands and feet, extremities, and buttock, and some cases manifest by seborrheic dermatitis-like eruption on the scalp and face; also palmo plantar keratosis has been reported.<ref name=BOLOGNIA2008 /><ref name=FITZPATRICK2003p472>{{cite book |editor1-first=Irwin M. |editor1-last=Freedberg | name-list-style = vanc |title=Fitzpatrick's dermatology in general medicine |year=2003 |publisher=McGraw-Hill |location=New York, NY |isbn=978-0-07-138076-8 |page=472 |edition=6th}}</ref><ref name=ANDREWS2006p224>{{cite book |first1=William D. |last1=James |first2=Dirk M. |last2=Elston |first3=Timothy G. |last3=Berger | name-list-style = vanc |title=Andrews' Diseases of the skin : clinical dermatology |url=https://archive.org/details/andrewsdiseasess00mdwi |url-access=limited |publisher=Saunders/ Elsevier |location=London |isbn=978-1-4377-0314-6 |edition=11th |page=[https://archive.org/details/andrewsdiseasess00mdwi/page/n232 224]|year=2011 }}</ref>
* ''Lichenoid keratoses'' (also known as "benign lichenoid keratosis", and "Solitary lichen planus"<ref name=BOLOGNIA2008 />) is a cutaneous condition characterized by brown to red scaling maculopapules, found on sun-exposed skin of extremities.<ref name=BOLOGNIA2008 /><ref name=FITZPATRICK2003p473>{{cite book |editor1-first=Irwin M. |editor1-last=Freedberg | name-list-style = vanc |title=Fitzpatrick's dermatology in general medicine |year=2003 |publisher=McGraw-Hill |location=New York, NY |isbn=978-0-07-138076-8 |page=473 |edition=6th}}</ref> Restated, this is a cutaneous condition usually characterized by a solitary dusky-red to violaceous papular skin lesion.<ref name=ANDREWS2006p639>{{cite book |first1=William D. |last1=James |first2=Dirk M. |last2=Elston |first3=Timothy G. |last3=Berger | name-list-style = vanc |title=Andrews' Diseases of the skin : clinical dermatology |url=https://archive.org/details/andrewsdiseasess00mdwi |url-access=limited |publisher=Saunders/ Elsevier |location=London |isbn=978-1-4377-0314-6 |edition=11th |page=[https://archive.org/details/andrewsdiseasess00mdwi/page/n647 639]|year=2011 }}</ref>
* ''Lichenoid dermatitis'' represents a wide range of cutaneous disorders characterized by lichen planus-like skin lesions.<ref name=BOLOGNIA2008 /><ref name=FITZPATRICK2003p473/>

===Mucous membranes===
[[File:Lichen Planus Fig7.tiff|thumbnail|Lichen planus on the lips and the lateral border of the tongue]]
Lichen planus affecting mucosal surfaces may have one lesion or be multifocal.<ref name="Ebrahimi 2012">{{cite journal | vauthors = Ebrahimi M, Lundqvist L, Wahlin YB, Nylander E | s2cid = 25165134 | title = Mucosal lichen planus, a systemic disease requiring multidisciplinary care: a cross-sectional clinical review from a multidisciplinary perspective | journal = Journal of Lower Genital Tract Disease | volume = 16 | issue = 4 | pages = 377–80 | date = October 2012 | pmid = 22622344 | doi = 10.1097/LGT.0b013e318247a907 }}</ref> Examples of lichen planus affecting mucosal surfaces include:<ref name="Ebrahimi 2012"/>
* ''[[Esophagus|Esophageal]] lichen planus'', affecting the esophageal mucosa. This can present with [[dysphagia|difficulty or pain when swallowing]] due to [[esophagitis|oesophageal inflammation]], or as the development of an [[esophageal stricture]]. It has also been hypothesized that it is a precursor to squamous cell carcinoma of the esophagus.<ref name=YAMADA2009>{{cite book|vauthors=Yamada T, Alpers DH |title=Textbook of gastroenterology|url=https://archive.org/details/textbookgastroen00yama_718 |url-access=limited |year=2009|publisher=Blackwell Pub.|location=Chichester, West Sussex|isbn=978-1-4051-6911-0|edition=5th|page=[https://archive.org/details/textbookgastroen00yama_718/page/n3326 3304]|display-authors=etal}}</ref><ref>{{cite journal | vauthors = Chandan VS, Murray JA, Abraham SC | title = Esophageal lichen planus | journal = Archives of Pathology & Laboratory Medicine | volume = 132 | issue = 6 | pages = 1026–9 | date = June 2008 | pmid = 18517264 | doi = 10.5858/2008-132-1026-ELP |url=https://www.archivesofpathology.org/doi/full/10.1043/1543-2165%282008%29132%5B1026%3AELP%5D2.0.CO%3B2| url-access = subscription }}</ref>
* ''Genital lichen planus,'' which may cause lesions on the [[glans penis]] or skin of the scrotum in males, and the vulva or vagina in females.<ref name="Le Cleach 2012" /> Symptoms may include [[lower urinary tract symptom]]s associated with [[stenosis]] of the [[urethra]], [[dyspareunia|painful sexual intercourse]], and itching.<ref name="Le Cleach 2012" />  In females, ''Vulvovaginal-gingival syndrome'', is severe and distinct variant affecting the [[vulva]], [[vagina]], and gums, with complications including scarring, vaginal stricture formation,<ref>{{cite journal | vauthors = Panagiotopoulou N, Wong CS, Winter-Roach B | s2cid = 45115301 | title = Vulvovaginal-gingival syndrome | journal = Journal of Obstetrics and Gynaecology | volume = 30 | issue = 3 | pages = 226–30 | date = April 2010 | pmid = 20373919 | doi = 10.3109/01443610903477572 }}</ref> or vulva destruction.<ref name="Schlosser 2010">{{cite journal | vauthors = Schlosser BJ | title = Lichen planus and lichenoid reactions of the oral mucosa | journal = Dermatologic Therapy | volume = 23 | issue = 3 | pages = 251–67 | date = May–Jun 2010 | pmid = 20597944 | doi = 10.1111/j.1529-8019.2010.01322.x | s2cid = 37730720 | doi-access = free }}</ref> The corresponding syndrome in males, affecting the glans penis and gums, is the ''peno-gingival syndrome''.<ref name=BOLOGNIA2008 /> It is associated with [[HLA-DQB1]].<ref name=BOLOGNIA2008 /><ref name="Nico 2011">{{cite journal | vauthors = Nico MM, Fernandes JD, Lourenço SV | title = Oral lichen planus | journal = Anais Brasileiros de Dermatologia | volume = 86 | issue = 4 | pages = 633–41; quiz 642–3 | date = Jul–Aug 2011 | pmid = 21987126 | doi = 10.1590/s0365-05962011000400002 | doi-access = free }}</ref>

====Mouth====
[[File:Lichen planus.jpg|thumb|Classic [[Wickham striae|Wickham's striae]] of non-erosive lichen planus in the left buccal mucosa (left cheek)]]
Oral lichen planus (also termed ''oral mucosal lichen planus''), is a form of mucosal lichen planus, where lichen planus involves the [[oral mucosa]], the lining of the mouth.<ref>{{cite journal | vauthors = Alam F, Hamburger J | title = Oral mucosal lichen planus in children | journal = International Journal of Paediatric Dentistry | volume = 11 | issue = 3 | pages = 209–14 | date = May 2001 | pmid = 11484471 | doi = 10.1046/j.1365-263X.2001.00266.x }}</ref> This may occur in combination with other variants of lichen planus. Six clinical forms of oral lichen planus (OLP) are recognized:<ref>{{cite journal | vauthors = Farhi D, Dupin N | title = Pathophysiology, etiologic factors, and clinical management of oral lichen planus, part I: facts and controversies | journal = Clinics in Dermatology | volume = 28 | issue = 1 | pages = 100–8 | year = 2010 | pmid = 20082959 | doi = 10.1016/j.clindermatol.2009.03.004 }}</ref>

; Reticular
: The most common presentation of oral lichen planus (OLP) is characterised by the net-like or spider web-like appearance of lacy white lines, known as [[Wickham striae|Wickham's striae]].<ref name=":0">{{Cite journal |last1=Lodi|first1=Giovanni|last2=Manfredi|first2=Maddalena|last3=Mercadante|first3=Valeria |last4=Murphy|first4=Ruth|last5=Carrozzo|first5=Marco|date=28 February 2020|title=Interventions for treating oral lichen planus: corticosteroid therapies|journal=The Cochrane Database of Systematic Reviews|volume=2020|issue=2|pages=CD001168|doi=10.1002/14651858.CD001168.pub3|issn=1469-493X|pmc=7047223|pmid=32108333}}</ref>  This is usually asymptomatic. Reticular OLP may progress to the more severe subtypes, such as the erosive form, if left untreated.<ref name=":1" />
; Erosive or ulcerative
: The second most common form and the most advanced form of oral lichen planus,<ref name=":0" /><ref name=":1" /> is characterised by [[mouth ulcer|oral ulcers]] presenting with persistent, irregular areas of [[erythema|redness]], ulcerations and erosions covered with a yellow slough.<!-- <ref name="Scully 2013" /> --> This can occur in one or more areas of the mouth. In 25% of people with erosive oral lichen planus, the gums are involved, described as [[desquamative gingivitis]] (a condition not unique to lichen planus). <!-- <ref name="Scully 2013" /> --> This may be the initial or only sign of the condition.<ref name="Scully 2013">{{cite book|title=Oral and maxillofacial medicine : the basis of diagnosis and treatment|last=Scully C|publisher=Churchill Livingstone|year=2008|isbn=9780702049484|edition=3rd|location=Edinburgh|pages=192–99}}</ref> Involvement of the dorsum of the tongue might cause an altered sense of taste (dysgeusia).<ref name=":1" />
; Papular
: This form is characterized by small white pinpoint papules that are asymptomatic. Hence, they can be easily missed during a routine checkup. It is referred to as the initial and transient phase of OLP.<ref name=":1" />
; Plaque-like
: Large, homogenous white patches are characteristic of this form which may resemble [[leukoplakia]]. This form is more prevalent in tobacco smokers.<ref name=":1" />
; Atrophic
: This form is a common presentation that has similarities to the erosive form. It has a more prominent atrophic lesion on a background of erythema with radiating white striae at the margins.<ref name=":1" /> Atrophic oral lichen planus may also manifest as desquamative gingivitis.<ref name="Scully 2013" />
; Bullous
: Rare form of OLP characterized by fluid-filled vesicles ranging in size from 1 to 2&nbsp;mm to several&nbsp;cm in diameter. The vesicles or bullae appear white or gray-purple in color and are fluctuant. The fluid in the vesicles are usually clear but may be hemorrhagic or purulent upon secondary infection. These rupture easily and they leave an ulcerated, painful surface.{{citation needed|date=December 2019}}

These types often coexist in the same individual. Oral lichen planus (OLP) tends to present bilaterally as mostly white lesions on the [[buccal mucosa|inner cheek]],<ref name=":0" /> although any mucosal site in the mouth may be involved. Other sites, in decreasing order of frequency, may include the tongue, lips, gingivae, floor of the mouth, and very rarely, the palate.<ref name=":0" />

Generally, oral lichen planus tends not to cause any discomfort or pain, although some people may experience soreness when eating or drinking acidic or spicy foodstuffs or beverages.<ref name="Scully 2013" /> When symptoms arise, they are most commonly associated with the atrophic and ulcerative subtypes. These symptoms can include a burning sensation to severe pain.<ref name=":0" /> They may also experience mucosal bleeding in response to mild trauma, such as toothbrushing. Additionally, the Koebner phenomenon (the development of new lesions at sites of trauma) is not only present in cutaneous lichen planus (CLP) but can also occur in the setting of OLP.

Residual postinflammatory hyperpigmentation has been reported in association with OLP, manifesting as brown to black pigmentation on the oral mucosa and may most likely occur in dark-skinned individuals.<ref name=":2">{{Cite web|url=https://www.uptodate.com/contents/oral-lichen-planus-pathogenesis-clinical-features-and-diagnosis?search=oral%20lichen%20planus&source=search_result&selectedTitle=2~25&usage_type=default&display_rank=2|title=UpToDate|website=www.uptodate.com|access-date=2019-01-04}}</ref>

OLP may occur as a sole manifestation of the disease or in conjunction with other clinical manifestations of LP, including cutaneous LP, genital LP, nail LP, and lichen planopilaris (scalp LP).<ref name=":2" />

==Causes==
Cutaneous LP is a self-limiting condition. It usually resolves within 6 to 12 months. Oral LP is a non infectious, chronic inflammatory condition that involves the oral mucosa and may be accompanied by skin lesions. The etiology of oral LP are unknown.{{citation needed|date=July 2022}}

It is not clear whether the mechanisms causing isolated oral LP are different from those causing oral LP with cutaneous LP. An immune-mediated mechanism where [[Stratum basale|basal keratinocytes]] are being targeted as foreign antigens by activated T cells, especially [[Cytotoxic T cell|CD8+]] T cells, has been proposed.<ref name="Lichen planus">{{cite journal | vauthors = Lehman JS, Tollefson MM, Gibson LE | title = Lichen planus | journal = International Journal of Dermatology | volume = 48 | issue = 7 | pages = 682–94 | date = July 2009 | pmid = 19570072 | doi = 10.1111/j.1365-4632.2009.04062.x | s2cid = 35881020 | doi-access = free }}</ref> Upregulation of intercellular adhesion molecule-1 ([[ICAM-1]]) and cytokines associated with T-helper 1 immune response, may also play an important role in the pathogenesis of lichen planus.{{citation needed|date=July 2022}}

Stress is thought to play a role in the pathogenesis of oral LP. Patients with anxiety and depression are reported more commonly with oral LP if compared to normal healthy individuals.<ref>{{cite journal | vauthors = McCartan BE | title = Psychological factors associated with oral lichen planus | journal = Journal of Oral Pathology & Medicine | volume = 24 | issue = 6 | pages = 273–5 | date = July 1995 | pmid = 7562664 | doi = 10.1111/j.1600-0714.1995.tb01181.x }}</ref><ref name = "Eisen_2002">{{cite journal | vauthors = Eisen D | title = The clinical features, malignant potential, and systemic associations of oral lichen planus: a study of 723 patients | journal = Journal of the American Academy of Dermatology | volume = 46 | issue = 2 | pages = 207–14 | date = February 2002 | pmid = 11807431 | doi = 10.1067/mjd.2002.120452 }}</ref> Some studies have indicated that stressful events can induce LP lesions in otherwise healthy individuals. However, a cause effect relationship between stress and the onset of oral LP has not been demonstrated.{{citation needed|date=November 2022}}

Autoimmune response to epithelial [[self-antigen]]s remains a possibility. A single study of cutaneous LP reported evidence in support of autoimmunity by expanding in vitro T cells isolated from the skin lesions of two patients, followed by testing the ability of these T cells to kill autologous keratinocytes (cytotoxicity).

Several potential triggers of oral LP have been proposed over the years, mainly

# [[Hypersensitivity|Hypersensitivity reaction]]
#* Restorative material (e.g. [[Amalgam (dentistry)|amalgam]]<ref name=":5">{{cite journal | vauthors = Schlosser BJ | title = Lichen planus and lichenoid reactions of the oral mucosa | journal = Dermatologic Therapy | volume = 23 | issue = 3 | pages = 251–67 | date = May 2010 | pmid = 20597944 | doi = 10.1111/j.1529-8019.2010.01322.x | s2cid = 37730720 | doi-access = free }}</ref> and composite) or drugs can cause hypersensitivity reaction and lead to oral LP.
#* Oral LP usually resolve upon removal of the trigger, as is characteristics of oral LP
# Viral infection

== Pathogenesis ==
Oral LP is considered to be a T-cell mediated chronic inflammatory tissue reaction that results in a cytotoxic reaction against epithelial basal cells.<ref name=":4">{{cite journal | vauthors = Roopashree MR, Gondhalekar RV, Shashikanth MC, George J, Thippeswamy SH, Shukla A | title = Pathogenesis of oral lichen planus--a review | journal = Journal of Oral Pathology & Medicine | volume = 39 | issue = 10 | pages = 729–34 | date = November 2010 | pmid = 20923445 | doi = 10.1111/j.1600-0714.2010.00946.x | s2cid = 3384200 }}</ref> The inflammatory infiltrate in oral LP is primarily composed of CD8+ T cells. A potential pathway for [[Cytotoxic T cell|CD8+]] T cell-mediated cytotoxicity in oral LP is described as follows:<ref name=":4" />

Antigens presented on [[MHC class I|MHC 1 molecules]] activates CD8+ T cells on keratinocytes or by encounters with activated CD4+ helper T cells or cytokines produced by activated CD4+ [[T helper cell|helper T cells]]{{citation needed|date=November 2022}}

Activated CD8+ T cells induce keratinocyte [[apoptosis]] through various mechanisms such as secretion of [[Tumor necrosis factor superfamily|tumor necrosis factor]] (TNF)-alpha, secretion of granzyme B, or Fas-Fas ligand interactions. Chemokines are produced by activated CD8+ T cells that attract additional inflammatory cells, thereby promoting continued inflammation.

Other mechanisms that have been proposed include:
* upregulation of [[matrix metalloproteinase]]s that disrupt the epithelial [[basement membrane]] zone and allow entry of immune cells into the epidermis,
* the release of proinflammatory mediators and proteases by mast cells, and
* perturbations in the innate immune response that may involve [[toll-like receptor]]s.<ref name=":4" /><ref>{{cite journal | vauthors = Siponen M, Kauppila JH, Soini Y, Salo T | title = TLR4 and TLR9 are induced in oral lichen planus | journal = Journal of Oral Pathology & Medicine | volume = 41 | issue = 10 | pages = 741–7 | date = November 2012 | pmid = 22672741 | doi = 10.1111/j.1600-0714.2012.01169.x }}</ref><ref>{{cite journal | vauthors = El Tawdy A, Rashed L | title = Downregulation of TLR-7 receptor in hepatic and non-hepatic patients with lichen planus | journal = International Journal of Dermatology | volume = 51 | issue = 7 | pages = 785–9 | date = July 2012 | pmid = 22715821 | doi = 10.1111/j.1365-4632.2011.04977.x | s2cid = 34765371 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Janardhanam SB, Prakasam S, Swaminathan VT, Kodumudi KN, Zunt SL, Srinivasan M | title = Differential expression of TLR-2 and TLR-4 in the epithelial cells in oral lichen planus | journal = Archives of Oral Biology | volume = 57 | issue = 5 | pages = 495–502 | date = May 2012 | pmid = 22119043 | doi = 10.1016/j.archoralbio.2011.10.013 }}</ref>

Oral LP may also be caused by genetic factor which influence the immune function. A separate study performed in China<ref name="Carrozzo M 2003">{{cite journal | vauthors = Carrozzo M, Uboldi de Capei M, Dametto E, Fasano ME, Arduino P, Broccoletti R, Vezza D, Rendine S, Curtoni ES, Gandolfo S | title = Tumor necrosis factor-alpha and interferon-gamma polymorphisms contribute to susceptibility to oral lichen planus | journal = The Journal of Investigative Dermatology | volume = 122 | issue = 1 | pages = 87–94 | date = January 2004 | pmid = 14962095 | doi = 10.1046/j.0022-202X.2003.22108.x | doi-access = free }}</ref> found an association between a polymorphism in the TNF-alpha gene and risk for oral LP in a subset of patients. An Italian study found a significant increase in a [[Polymorphism (biology)|genetic polymorphism]] of the first intron of the interferon (IFN)-gamma promoter in patients with oral LP compared with controls.<ref name="Carrozzo M 2003"/>

==Diagnosis==

=== Skin ===
Patient history and clinical presentation need to be taken to diagnose lichen planus. Patients with suspected cutaneous lichen planus need to be evaluated clinically through patient interviews and physical examinations. Patients should be questioned about their medication history, any history of [[Itch|pruritus]] or genital pain and history of [[dysphagia]] or [[odynophagia]]. Examination of entire cutaneous surface including the scalp, oral cavity and external genitalia need to be included. Wickham's striae often can be seen during microscopic examination of cutaneous lesions of lichen planus.<ref name=":7">{{Cite journal|last1=Lallas|first1=A.|last2=Kyrgidis|first2=A.|last3=Tzellos|first3=T. G.|last4=Apalla|first4=Z.|last5=Karakyriou|first5=E.|last6=Karatolias|first6=A.|last7=Lefaki|first7=I.|last8=Sotiriou|first8=E.|last9=Ioannides|first9=D.|date=June 2012|title=Accuracy of dermoscopic criteria for the diagnosis of psoriasis, dermatitis, lichen planus and pityriasis rosea|journal=The British Journal of Dermatology|volume=166|issue=6|pages=1198–1205|doi=10.1111/j.1365-2133.2012.10868.x|issn=1365-2133|pmid=22296226|s2cid=1468632}}</ref><ref>{{Cite journal|last1=Friedman|first1=Paula|last2=Sabban|first2=Emilia Cohen|last3=Marcucci|first3=Carolina|last4=Peralta|first4=Rosario|last5=Cabo|first5=Horacio|date=October 2015|title=Dermoscopic findings in different clinical variants of lichen planus. Is dermoscopy useful?|journal=Dermatology Practical & Conceptual|volume=5|issue=4|pages=51–55|doi=10.5826/dpc.0504a13|issn=2160-9381|pmc=4667604|pmid=26693092}}</ref>

To confirm the diagnosis of cutaneous lichen planus, a [[skin biopsy]] can be done. A [[Skin biopsy#Punch biopsy|punch biopsy]] of sufficient depth to the mid dermis is usually significant. [[Immunofluorescence]] studies are not always needed. [[Direct fluorescent antibody|Direct immunofluorescence]] (DIF) can be useful in patients with bullous lesions to differentiate the condition from an autoimmune [[vesiculobullous disease]].<ref>{{Citation|last=Weedon|first=David|title=The lichenoid reaction pattern ('interface dermatitis')|date=2010|work=Weedon's Skin Pathology|pages=35–70.e41|publisher=Elsevier|isbn=9780702034855|doi=10.1016/b978-0-7020-3485-5.00004-8}}</ref>

=== Mouth ===
A diagnosis of oral lichen planus (LP) is confirmed through review of the patient history, physical examination, and histologic findings.{{citation needed|date=July 2022}}

The clinical evaluation should include a patient history that assesses the following:
* History of LP involving other body sites or other skin disorders that may present with similar findings (e.g., autoimmune blistering diseases)
* Presence of associated symptoms (e.g., pain, burning)
* Medication the patients are taking within the few weeks to months after drug initiation e.g. [[Antihypertensive drug|antihypertensives]], [[antidepressant]]s, [[diuretic]]s, [[Anti-diabetic medication|antidiabetics]], [[Nonsteroidal anti-inflammatory drug|NSAIDs]], etc. to evaluate for the possibility of an oral lichenoid drug eruption
* History of dental restorations,<ref name=":5" /> use of dental appliances, or oral exposure to substances that may cause oral lichenoid contact eruptions (e.g. dental composites, cobalt chromium based dentures etc.)

A full examination that includes the evaluation of the mucosal and cutaneous surfaces, including the vulva, vagina, penis, scalp, and nails should be performed. Thorough examination may lead to the detection of extraoral manifestations of LP that provide additional support for the diagnosis or the identification of clinical findings that suggest another diagnosis.

Tissue biopsies of oral LP help to confirm the diagnosis and are particularly of value for erythematous and erosive LP, which share features with multiple other mucosal disorders, including oral malignancy. Biopsies to confirm oral LP are less essential in patients who present with classic reticular LP, particularly in patients in whom a diagnosis of LP has already been confirmed through biopsy of an extraoral manifestation of this disorder.<ref>{{cite journal | vauthors = Agha R, Mirowski GW | title = The art and science of oral examination | journal = Dermatologic Therapy | volume = 23 | issue = 3 | pages = 209–19 | date = May 2010 | pmid = 20597940 | doi = 10.1111/j.1529-8019.2010.01318.x | s2cid = 6367644 }}</ref><ref>{{cite journal | vauthors = Eisen D | title = The oral mucosal punch biopsy. A report of 140 cases | journal = Archives of Dermatology | volume = 128 | issue = 6 | pages = 815–7 | date = June 1992 | pmid = 1599270 | doi = 10.1001/archderm.1992.01680160099013 }}</ref>

=== Differential diagnosis ===

==== Skin ====

# [[Lichenoid drug eruption]]
#* The cutaneous manifestations resemble idiopathic lichen planus.
# Chronic graft-versus-host disease
#* The history of preceding hematopoietic cell transplant is helpful for diagnosis
# [[Psoriasis]]
# [[Atopic dermatitis]]
# Cutaneous [[lupus erythematosus]]
# [[Discoid lupus erythematosus]]<ref name=":7" />

====Mouth====

=====Oral lichenoid drug reaction=====
Lichenoid drug eruptions may be caused by a variety of systemic medications and share clinical features with oral LP. Histologic findings of a deep mixed infiltrate with [[lymphocyte]]s, [[plasma cell]]s, and [[neutrophil]]s (with or without eosinophils) and perivascular inflammation favor this diagnosis.

=====Oral lichenoid contact reaction (allergic contact mucositis)=====
Oral lichenoid contact reactions may be caused by a variety of substances. The clinical and histologic features of oral lichenoid contact reactions are similar to oral LP. Patch testing and recognition of the proximity of an offending substance to the eruption can aid with diagnosis.<ref name="Schlosser 2010" />

=====Autoimmune blistering diseases=====
[[Mucous-membrane pemphigoid|Mucous membrane pemphigoid]] and other autoimmune blistering diseases may present with oral erosions and [[desquamative gingivitis]] similar to that seen in erosive LP. Biopsies for routine histologic examination and direct immunofluorescence are useful for distinguishing these disorders from oral LP.

=====Graft-versus-host disease (GVHD)=====
Lacy, reticulated plaques or erosions that resemble oral LP may occur in GVHD. The histologic findings of these disorders are also similar. The patient history is useful for differentiating chronic GVHD from oral LP.<ref>{{cite journal | vauthors = Vargas-Díez E, García-Díez A, Marín A, Fernández-Herrera J | title = Life-threatening graft-vs-host disease | journal = Clinics in Dermatology | volume = 23 | issue = 3 | pages = 285–300 | date = May 2005 | pmid = 15896544 | doi = 10.1016/j.clindermatol.2004.06.005 }}</ref> Oral involvement in acute GVHD is less well characterized than chronic GVHD, but has been associated with erythematous, erosive, ulcerative, or lichenoid oral lesions.

=====Leukoplakia=====
[[File:Leukoplakia02-04-06.jpg|thumb|Leukoplakia]]
[[Leukoplakia]] is a manifestation of squamous epithelial [[hyperplasia]] that may be a precursor to oral squamous cell carcinoma. White patches or plaques usually appear on the oral mucosa. To rule out malignancy, a biopsy of leukoplakia is indicated.<ref>{{cite journal | vauthors = Warnakulasuriya S, Johnson NW, van der Waal I | title = Nomenclature and classification of potentially malignant disorders of the oral mucosa | journal = Journal of Oral Pathology & Medicine | volume = 36 | issue = 10 | pages = 575–80 | date = November 2007 | pmid = 17944749 | doi = 10.1111/j.1600-0714.2007.00582.x | doi-access = free }}</ref>

=====Oral squamous cell carcinoma=====
[[Oral squamous cell carcinoma]] (SCC) can present as erythematous or white patches, ulcers, or exophytic masses. The highest risk for oral SCC may occur in patients with erythematous or erosive oral LP.<ref>{{cite journal | vauthors = van der Meij EH, Mast H, van der Waal I | title = The possible premalignant character of oral lichen planus and oral lichenoid lesions: a prospective five-year follow-up study of 192 patients | journal = Oral Oncology | volume = 43 | issue = 8 | pages = 742–8 | date = September 2007 | pmid = 17112770 | doi = 10.1016/j.oraloncology.2006.09.006 }}</ref><ref>{{cite journal | vauthors = Hietanen J, Paasonen MR, Kuhlefelt M, Malmström M | title = A retrospective study of oral lichen planus patients with concurrent or subsequent development of malignancy | journal = Oral Oncology | volume = 35 | issue = 3 | pages = 278–82 | date = May 1999 | pmid = 10621848 | doi = 10.1016/S1368-8375(98)00116-X }}</ref><ref>{{cite journal | vauthors = Parashar P | title = Oral lichen planus | journal = Otolaryngologic Clinics of North America | volume = 44 | issue = 1 | pages = 89–107, vi | date = February 2011 | pmid = 21093625 | doi = 10.1016/j.otc.2010.09.004 }}</ref> A biopsy is indicated.

=====Leukoedema=====
[[Leukoedema]] is a common, benign finding in the oral cavity that presents as white-gray, somewhat translucent plaques on the mucosa. The [[Oral mucosa|buccal mucosa]] is the most common site for involvement. Symptoms are absent, and no treatment is necessary.<ref>{{cite journal | vauthors = Duncan SC, Su WP | title = Leukoedema of the oral mucosa. Possibly an acquired white sponge nevus | journal = Archives of Dermatology | volume = 116 | issue = 8 | pages = 906–8 | date = August 1980 | pmid = 7406518 | doi = 10.1001/archderm.1980.01640320056014 }}</ref><ref>{{cite journal | vauthors = Martin JL | title = Leukoedema: a review of the literature | journal = Journal of the National Medical Association | volume = 84 | issue = 11 | pages = 938–40 | date = November 1992 | pmid = 1460680 | pmc = 2571748 }}</ref>

=====Oropharyngeal candidiasis=====
Oropharyngeal [[candidiasis]] (also known as thrush) is a common infection that has a predilection for infants, older adults with dentures, immunosuppressed individuals, and individuals utilizing intraoral [[corticosteroid]] therapy. Patients present with white plaques or erythematous patches on the buccal mucosa, palate, tongue, or oropharynx that may be mistaken for reticular LP.<ref>{{cite journal | vauthors = Shay K, Truhlar MR, Renner RP | title = Oropharyngeal candidosis in the older patient | journal = Journal of the American Geriatrics Society | volume = 45 | issue = 7 | pages = 863–70 | date = July 1997 | pmid = 9215341 | doi = 10.1111/j.1532-5415.1997.tb01517.x | hdl = 2027.42/111172 | s2cid = 46075976 | url = https://deepblue.lib.umich.edu/bitstream/2027.42/111172/1/j.1532-5415.1997.tb01517.x.pdf | hdl-access = free }}</ref>

=== Histopathology ===
{{further|Histopathologic diagnosis of dermatitis}}
[[File:Lichen planus intermed mag.jpg|thumb|Histopathology of lichen planus]]

The histologic findings of oral LP can offer strong support for the diagnosis, but are not pathognomonic. Clinical correlation is required. Common histologic findings of oral LP include:<ref name=":5"/>
* [[Parakeratosis]] and slight acanthosis of the epithelium
* Saw-toothed rete ridges
* Liquefaction (hydropic) degeneration of the [[Stratum basale|basal layer]] with apoptotic keratinocytes (referred to as Civatte, colloid, hyaline, or cytoid bodies)
* An amorphous band of eosinophilic material at the basement membrane composed of fibrin or fibrinogen.
* A lichenoid (band-like) lymphocytic infiltrate immediately subjacent to the epithelium.

Nonetheless, interpreting the histopathological features of oral LP has been associated historically with high intra-observer and inter-observer variabilities.<ref>Majdy Idrees, Camile S Farah, Syed Ali Khurram, Norman Firth, Merva Soluk-Tekkesin, Omar Kujan. 2021, Observer agreement in the diagnosis of oral lichen planus using the proposed criteria of the American Academy of Oral and Maxillofacial Pathology. J Oral Pathol Med 2021 Mar 17. doi:10.1111/jop.13170</ref>

==Treatment==
<!-- ONLY SOURCES WHICH MEET THE SOURCING POLICY FOR MEDICAL CONTENT ON WIKIPEDIA TO BE INCLUDED (SEE: http://en.wikipedia.org/wiki/MEDRS ), CONTENT BASED ON UNSUITABLE SOURCES WILL BE REMOVED -->

There is no cure for lichen planus,<ref name=":0" /> and so treatment of cutaneous and oral lichen planus is for symptomatic relief or due to cosmetic concerns.<ref name="TG2009" /><ref name=":0" /><ref name="Kerawala 2010">{{cite book|title=Oral and maxillofacial surgery|publisher=Oxford University Press|year=2010|isbn=978-0-19-920483-0|veditors=Kerawala C, Newlands C|location=Oxford|pages=412–13}}</ref> When medical treatment is pursued, first-line treatment typically involves either topical or systemic [[corticosteroid]]s,<ref name="TG2009" /> and removal of any triggers.<ref name="ISSA2004">{{cite journal | vauthors = Issa Y, Brunton PA, Glenny AM, Duxbury AJ | title = Healing of oral lichenoid lesions after replacing amalgam restorations: a systematic review | journal = Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology| volume = 98 | issue = 5 | pages = 553–65 | date = November 2004 | pmid = 15529127 | doi = 10.1016/j.tripleo.2003.12.027 }}</ref> Without treatment, most lesions will spontaneously resolve within 6–9 months for cutaneous lesions,<ref name="TG2009" /> and longer for mucosal lesions.<ref name=SCULLY1985>{{cite journal|last=Scully|first=C.|author2=El-Kom, M. |title=Lichen planus: review and update on pathogenesis|journal=Journal of Oral Pathology and Medicine|date=1 July 1985|volume=14|issue=6|pages=431–58 |doi=10.1111/j.1600-0714.1985.tb00516.x|pmid=3926971}}</ref>

===Skin===
Many different treatments have been reported for cutaneous lichen planus, however there is a general lack of evidence of efficacy for any treatment.<ref name="CRIBIER1998">{{cite journal | vauthors = Cribier B, Frances C, Chosidow O | title = Treatment of lichen planus. An evidence-based medicine analysis of efficacy | journal = Archives of Dermatology | volume = 134 | issue = 12 | pages = 1521–30 | date = December 1998 | pmid = 9875189 | doi = 10.1001/archderm.134.12.1521 | doi-access =  }}</ref><ref>{{cite journal | vauthors = Antiga E, Caproni M, Parodi A, Cianchini G, Fabbri P | title = Treatment of cutaneous lichen planus: an evidence based analysis of efficacy by the Italian Group for Cutaneous Immunopathology | journal = Giornale Italiano di Dermatologia e Venereologia | volume = 149 | issue = 6 | pages = 719–26 | date = December 2014 | pmid = 25664824 }}</ref> The mainstay of localized skin lesions is topical steroids.<ref name=":0" /> Additional treatments include [[retinoid]]s, such as [[acitretin]], or [[sulfasalazine]]. Narrow band UVB phototherapy or systemic [[PUVA therapy]] are known treatment modalities for generalized disease.<ref name="Lichen planus"/>

===Mouth===
Reassurance that the condition is benign, elimination of precipitating factors and improving [[oral hygiene]] are considered initial management for symptomatic OLP, and these measures are reported to be useful.<ref name=":0" /> Treatment usually involves [[topical medication|topical]] [[corticosteroids]] (such as [[betamethasone]],<!-- <ref name="Thongprasom 2011" /> --> [[clobetasol]],<!-- <ref name="Thongprasom 2011" /> --> [[dexamethasone]],<!-- <ref name="Thongprasom 2011" /> --> and [[triamcinolone]]<!-- <ref name="Thongprasom 2011" /> -->) and [[analgesic]]s, or if these are ineffective and the condition is severe, then systemic corticosteroids may be used. [[Calcineurin inhibitor]]s (such as [[pimecrolimus]],<!-- <ref name="Thongprasom 2011" /> --> [[tacrolimus]]<!-- <ref name="Thongprasom 2011" /> --> or [[cyclosporin]]<!-- <ref name="Thongprasom 2011" />  and [[retinoid]]s (such as [[tretinoin]]--><!-- <ref name="Thongprasom 2011" /> -->) are sometimes used.<ref name=":0" /> While topical steroids are widely accepted as first line treatment for mucosal lichen planus, there is only weak evidence to support their effectiveness for erosive oral lichen planus.<ref>{{cite journal | vauthors = Cheng S, Kirtschig G, Cooper S, Thornhill M, Leonardi-Bee J, Murphy R | title = Interventions for erosive lichen planus affecting mucosal sites | journal = The Cochrane Database of Systematic Reviews | issue = 2 | pages = CD008092 | date = February 2012 | volume = 2015 | pmid = 22336835 | doi = 10.1002/14651858.CD008092.pub2 | url = http://www.cochrane.org/CD008092/SKIN_treatments-erosive-lichen-planus-affecting-mucosal-sites | hdl = 1871/48562 | pmc = 10794897 }}</ref>

==Prognosis==
Cutaneous lichen planus lesions typically resolve within six months to a year. However, some variant such as the hypertrophic variant might persist for years if left untreated or unmonitored.<ref name=":1"/>

It is found that cutaneous lichen planus does not carry a risk of [[skin cancer]].<ref name=":3">{{Cite web|author=Tsu-Yi Chuang |date=Feb 24, 2020|title=Lichen Planus: Practice Essentials, Background, Pathophysiology |url=https://emedicine.medscape.com/article/1123213-overview#a2}}</ref> In contrast to cutaneous LP, which is self limited, lichen planus lesions in the mouth may persist for many years,<ref name="Kerawala 2010" /> and tend to be difficult to treat, with relapses being common.<ref name="Nico 2011" /><ref name=":1"/>

Although this condition was first described almost a century ago, it has been reported that its associated oral cancer risk has been exaggerated.<ref>{{cite journal |last1=Idrees |first1=M |last2=Kujan |first2=O |last3=Shearston |first3=K |last4=Farah |first4=CS |title=Oral lichen planus has a very low malignant transformation rate: A systematic review and meta-analysis using strict diagnostic and inclusion criteria. |journal=Journal of Oral Pathology & Medicine |date=25 January 2020 |volume=50 |issue=3 |pages=287–298 |doi=10.1111/jop.12996 |pmid=31981238|s2cid=210891674 |url=https://research-repository.uwa.edu.au/en/publications/80781e51-7aa2-4e2b-89f9-509617775468 }}</ref>
Overall, it is found that patients with erythematous or erosive oral lichen planus have a higher risk of [[Squamous cell carcinoma|oral squamous cell carcinoma]] compared to patients diagnosed with other variants.<ref name=":6">{{Cite web|url=https://www.uptodate.com/contents/oral-lichen-planus-management-and-prognosis?search=lichen%20planus%20management%20and%20prognosis&source=search_result&selectedTitle=2~113&usage_type=default&display_rank=2|title=UpToDate|website=www.uptodate.com|access-date=2019-01-07}}</ref>

Due to the possibility that oral LP may increase risk for [[oral cancer]], patients with oral lichen planus are encouraged to avoid activities known to increase the risk for oral cancer, such as smoking and alcohol use.<ref name=":6" /><ref name=":3" />

Patients with oral lichen planus should be followed-up at least every 6 to 12 months, to assess the disease activity, changes in symptoms or even detect early signs of [[malignancy]].<ref name=":6" />

==Epidemiology==
The overall estimated [[prevalence]] of lichen planus in worldwide population is in the range of 0.2% to 5%.<ref name="Le Cleach 2012" /><ref name="Miller CS 2001">{{cite journal | vauthors = Miller CS, Epstein JB, Hall EH, Sirois D | title = Changing oral care needs in the United States: the continuing need for oral medicine | journal =   Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology| volume = 91 | issue = 1 | pages = 34–44 | date = January 2001 | pmid = 11174569 | doi = 10.1067/moe.2001.110439 }}</ref><ref name="ReferenceA">{{cite journal | vauthors = Bouquot JE, Gorlin RJ | title = Leukoplakia, lichen planus, and other oral keratoses in 23,616 white Americans over the age of 35 years | journal = Oral Surgery, Oral Medicine, and Oral Pathology | volume = 61 | issue = 4 | pages = 373–81 | date = April 1986 | pmid = 3458148 | doi = 10.1016/0030-4220(86)90422-6 }}</ref><ref>{{cite journal | vauthors = Axéll T, Rundquist L | title = Oral lichen planus--a demographic study | journal = Community Dentistry and Oral Epidemiology | volume = 15 | issue = 1 | pages = 52–6 | date = February 1987 | pmid = 3467894 | doi = 10.1111/j.1600-0528.1987.tb00480.x }}</ref><ref>{{cite journal | vauthors = Alabi GO, Akinsanya JB | title = Lichen planus in tropical Africa | journal = Tropical and Geographical Medicine | volume = 33 | issue = 2 | pages = 143–7 | date = June 1981 | pmid = 7281214 }}</ref><ref>{{cite journal | vauthors = Li TJ, Cui J | title = COX-2, MMP-7 expression in oral lichen planus and oral squamous cell carcinoma | journal = Asian Pacific Journal of Tropical Medicine | volume = 6 | issue = 8 | pages = 640–3 | date = August 2013 | pmid = 23790336 | doi = 10.1016/s1995-7645(13)60110-8 | doi-access = free }}</ref>

It generally occurs more commonly in females, in a ratio of 3:2, and most cases are diagnosed between the ages of 30 and 60, but it can occur at any age.<ref name="Le Cleach 2012" /><ref>{{cite journal | vauthors = Yu TC, Kelly SC, Weinberg JM, Scheinfeld NS | title = Isolated lichen planus of the lower lip | journal = Cutis | volume = 71 | issue = 3 | pages = 210–2 | date = March 2003 | pmid = 12661749 }}</ref><ref name = "Eisen_2002" />

Lichen planus can occur in patients as diverse cutaneous manifestations alone or in combination with mucosal lichen planus and, or lichen planus of the nails. Study shows that frequency of mucosal involvement of lichen planus patients is 30- 70%.<ref name="Clinical variants of lichen planus"/>

Oral lichen planus is relatively common,<ref name="Nico 2011" /> It is one of the most common mucosal diseases. The [[prevalence]] in the general population is about 1.27–2.0%,<ref name=":0" /><ref name="Kerawala 2010" /> and it occurs more commonly in middle aged people.<ref name=":0" /> Oral lichen planus in children is rare. About 50% of females with oral lichen planus were reported to have undiagnosed vulvar lichen planus.<ref name="Le Cleach 2012" />

Some studies suggest that cutaneous lichen planus is more commonly found in men whilst oral lichen planus lesions are more commonly found in women.<ref>{{cite journal | vauthors = McCartan BE, Healy CM | title = The reported prevalence of oral lichen planus: a review and critique | journal = Journal of Oral Pathology & Medicine | volume = 37 | issue = 8 | pages = 447–53 | date = September 2008 | pmid = 18624932 | doi = 10.1111/j.1600-0714.2008.00662.x }}</ref><ref>{{cite journal | vauthors = Carbone M, Arduino PG, Carrozzo M, Gandolfo S, Argiolas MR, Bertolusso G, Conrotto D, Pentenero M, Broccoletti R | title = Course of oral lichen planus: a retrospective study of 808 northern Italian patients | journal = Oral Diseases | volume = 15 | issue = 3 | pages = 235–43 | date = April 2009 | pmid = 19222766 | doi = 10.1111/j.1601-0825.2009.01516.x }}</ref><ref>{{cite journal | vauthors = Hellgren L | title = The prevalence of rheumatoid arthritis in different geographical areas in Sweden | journal = Acta Rheumatologica Scandinavica | volume = 16 | issue = 4 | pages = 293–303 | date = December 1970 | pmid = 5493043 | doi = 10.3109/rhe1.1970.16.issue-1-4.34 }}</ref><ref>{{cite journal | vauthors = Nagao T, Ikeda N, Fukano H, Hashimoto S, Shimozato K, Warnakulasuriya S | title = Incidence rates for oral leukoplakia and lichen planus in a Japanese population | journal = Journal of Oral Pathology & Medicine | volume = 34 | issue = 9 | pages = 532–9 | date = October 2005 | pmid = 16138891 | doi = 10.1111/j.1600-0714.2005.00349.x }}</ref><ref>{{cite journal | vauthors = Xue JL, Fan MW, Wang SZ, Chen XM, Li Y, Wang L | title = A clinical study of 674 patients with oral lichen planus in China | journal = Journal of Oral Pathology & Medicine | volume = 34 | issue = 8 | pages = 467–72 | date = September 2005 | pmid = 16091113 | doi = 10.1111/j.1600-0714.2005.00341.x }}</ref><ref>{{cite journal | vauthors = Thorn JJ, Holmstrup P, Rindum J, Pindborg JJ | title = Course of various clinical forms of oral lichen planus. A prospective follow-up study of 611 patients | journal = Journal of Oral Pathology | volume = 17 | issue = 5 | pages = 213–8 | date = May 1988 | pmid = 3144584 | doi = 10.1111/j.1600-0714.1988.tb01527.x }}</ref>

==History==
Lichen planus was first described in 1869 by [[Erasmus Wilson]] as an inflammatory disorder with unknown etiology. Initially, the characteristic surface markings or striae was described by Weyl in 1885. In 1895, Wickham further explained the characteristic of the lesion, now known as Wickham striae. Further on, Darier explained the presence of such characteristic markings by correlating with an increase thickness of the granular cell layer. The coexistence of oral, cervical and stomach lichen planus lesions were described by Guogerot and Burnier in 1937. A similar variant of mucosal lichen planus as the vulvovaginal-gingival syndrome with erosive lesions involving oral and vulvovaginal mucosa were introduced by Pelisse and colleagues in year 1982.<ref name=":1"/>

The origin of the word is believed to be from the Greek word <nowiki>''Leichen'', which means tree moss, and also from Latin word ''planus''</nowiki>, which means flat and even surface.

== Research ==
[[Apremilast]] is undergoing investigation as a potential treatment.<ref>{{cite journal | vauthors = Paul J, Foss CE, Hirano SA, Cunningham TD, Pariser DM | title = An open-label pilot study of apremilast for the treatment of moderate to severe lichen planus: a case series | journal = Journal of the American Academy of Dermatology | volume = 68 | issue = 2 | pages = 255–61 | date = February 2013 | pmid = 22910104 | doi = 10.1016/j.jaad.2012.07.014 }}</ref>

== Explanatory notes ==
{{Notelist}}

== References ==
{{Reflist|30em}}

== External links ==
*{{commons category-inline}}

{{Medical resources
|  DiseasesDB = 7452
|  ICD10 = {{ICD10|L|43||l|40}}
|  ICD9 = {{ICD9|697.0}}
|  ICDO =
|  OMIM =
|  MedlinePlus = 000867
|  eMedicineSubj = derm
|  eMedicineTopic = 233
|  eMedicine_mult = {{eMedicine2|derm|663}}
|  MeshID = D008010
| meSH2           = D017676
}}
{{Diseases of the skin and appendages by morphology}}
{{Papulosquamous disorders}}
{{oral pathology}}
{{Authority control}}

{{DEFAULTSORT:Lichen Planus}}
[[Category:Autoimmune diseases]]
[[Category:Conditions of the mucous membranes]]
[[Category:Hepatitis C virus-associated diseases]]
[[Category:Lichenoid eruptions]]
[[Category:Oral mucosal pathology]]