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Clinical Features

  • Classic Lichen planus
    • Pruritic, polygonal, Purple, Plane (flat-topped) papules ± umbilication, coalescence, “Wickham striae”, Koebner phenomenon
      • Resolves in <1 year ± post-inflammatory hyperpigmentation
      • Flexor wrists, forearms, dorsal hands, shins, presacral
      • 75% mucosal involvement (may be the only sign of disease)

Clinical variants

  • Children/young adults
  • Spring/summer onset 🡪 resolves during the winter
  • Photodistributed annular lesions

  • Rapid dissemination 
  • Resolves spontaneously in 3-9 months with post inflammatory hyperpigmentation
  • Trunk, inner wrists, dorsal feet

  • Peripheral spread with central resolution
  • Raised edges
  • Axilla > penis, extremities, groin

  • Resolving lichen planus with post inflammatory hyperpigmentation
  • Intertriginous areas, lower extremities

  • Vesicles/bullae form in pre-existing lichen planus lesions
  • Caused by intense lichenoid inflammation

  • Immunoglobulin G autoantibodies against bullous pemphigoid antigen180 (bullous pemphigoid antigen 2)
  • Causes bullae in lichen planus lesions or uninvolved skin

  • Hyperkeratotic violaceous pruritic plaques
  • Chronic lesions are secondary to repetitive scratching
  • Increased risk of squamous cell carcinoma 
  • Shins, dorsum of the foot

  • Papules/plaques
  • Intertriginous areas

  • Most common in skin types III/IV (South Asia, Latin America, Middle East)
  • Gray-brown macules 
  • Sun exposed areas > intertriginous areas, blaschkoid
  • Clinical and histologic overlap with Ashy dermatosis

  • Females > males
  • Keratotic plugs + perifollicular erythema of scalp
  • Scarring alopecia
  • Variant: Graham-Little-Piccardi-Lassueur
    • Non-cicatricial pubic/axillary alopecia + disseminated spinous follicular papules
    • Lichen planus lesions
    • Scarring alopecia ± atrophy
  • Variant: frontal fibrosing alopecia
    • Alopecia of scalp + eyebrows
    • Older women

  • Lesions arising in lines of Blaschko 

  • Both lichen planus and lupus erythematosus lesions
  • Acral areas

  • ~10% patients, usually isolated nail disease
  • Persistent
  • Matrix damage 🡪 lateral thinning, longitudinal ridging, fissuring, dorsal pterygium
  • Nail bed changes 🡪 yellowing, onycholysis, subungual hyperkeratosis
  • Variant: twenty-nail dystrophy: children > adults

  • Uncommon in young patients
  • Females > males
  • Persistent
  • 7 different forms
    • Most common: reticular 🡪 bilateral, symmetric, asymptomatic
    • Atrophic/bullous/erosive 🡪 symptomatic
    • Papular, pigmented
    • Plaque-like 🡪 associated with tobacco smokers
  • Screen for esophageal lichen planus (dysphagia, strictures, stenosis)
  • Increased risk of squamous cell carcinoma (mainly for erosive/bullous forms)

  • Females > males
  • Painful palmoplantar ulcers
  • Increased risk of squamous cell carcinoma 
  • Refractory to therapy

  • Females > Males 
  • Erosive vulvovaginal lesions
  • Chronic desquamative gingivitis, 
  • Increased risk of squamous cell carcinoma

  • ~ 65 years old
  • Generalized/photodistributed, spares mucosae
  • Eczematous/psoriasiform/pityriasis rosea-like
  • Appears ~12 months post-drug introduction
  • Resolves within weeks to months after discontinuation