Prescription for Lichen Planus

Step 1 - Remove Triggers First

• Identify and discontinue any lichenoid drug reactions (ACE inhibitors, beta-blockers, gold, antimalarials, NSAIDs, thiazides, penicillamine, proton pump inhibitors)
• Minimize trauma (to prevent Koebnerization)
• Reduce microbial overgrowth (especially candida in oral LP)
• Address associated conditions: hepatitis C should be screened for in all LP patients

Topical Therapy (First-Line for Limited Cutaneous LP)

High-Potency Topical Corticosteroids

• Clobetasol propionate 0.05% ointment - apply twice daily; first-line for most cutaneous LP
• For hypertrophic LP: use under occlusion to improve penetration
• If no response in 2-4 weeks, escalate to higher potency or intralesional route
• Reduce to moderately potent CS (e.g. mometasone furoate 0.1%) for maintenance

Topical Calcineurin Inhibitors (Second-Line Topical)

• Tacrolimus 0.1% ointment - as effective as clobetasol 0.05% in oral LP; used when steroids are not tolerated or to spare steroid atrophy
• Pimecrolimus 1% cream - alternative, especially for mucosal/anogenital sites
• Often combined with topical corticosteroids to allow steroid tapering

Intralesional Corticosteroids

• Triamcinolone acetonide 5-10 mg/mL injected monthly
• Highly effective for hypertrophic LP and resistant lesions
• Must combine with topical therapy to prevent relapse; avoid excess trauma

Systemic Therapy (For Severe, Widespread, or Refractory LP)

First-Line Systemic: Oral Corticosteroids

• Prednisolone 0.3-1 mg/kg/day for 4-6 weeks, followed by a 4-6 week taper
• 90% response rate; 32% relapse at 6 months
• Always combine with topical therapy or a steroid-sparing agent - monotherapy not recommended long-term
• For oral LP: betamethasone 5 mg on 2 consecutive days per week for 3 months (mini-pulse) is an alternative
• Add antifungal prophylaxis for oral LP (candida risk)

Second-Line (Corticosteroid-Sparing) Agents

Third-Line / Refractory Disease

• Cyclosporine 2.5-5 mg/kg/day - effective but use limited by nephrotoxicity and hypertension; third-line
• Azathioprine 1-3 mg/kg/day - less preferred second-line agent; use with TPMT level monitoring
• TNF-alpha inhibitors (e.g., adalimumab, etanercept) - anecdotal case series; third-line
• JAK inhibitors (tofacitinib, ruxolitinib) - emerging; target CD8+ T cells (disease-specific mechanism); promising in refractory and lichen planopilaris
• Systemic antibiotics - tetracyclines ± nicotinamide: small evidence, third-line
• Phototherapy - NB-UVB or PUVA for generalized cutaneous LP

Oral Lichen Planus - Specific Prescriptions

• Topical clobetasol 0.05% gel or ointment applied to affected mucosa after meals and at bedtime (can compound in Orabase)
• Topical tacrolimus 0.1% ointment - as effective as clobetasol; useful for maintenance
• Topical cyclosporine 100 mg/mL as oral rinse - hold for 5 min then spit
• Systemic hydroxychloroquine 200-400 mg/day for 6-12 months - improvement in erosions at 3-6 months
• Oral acitretin preferred over immunosuppressants for noneroded/hyperkeratotic oral LP (antiproliferative effect reduces malignant transformation risk)
• Methotrexate 10-15 mg weekly preferred for erosive oral LP
• Monitor for oral SCC (risk ~2.4% for erosive LP) at every visit

Scalp LP (Lichen Planopilaris)

• High-potency topical CS to scalp (clobetasol solution/foam) - first-line
• Intralesional triamcinolone 5-10 mg/mL - for active areas
• Hydroxychloroquine 200-400 mg/day - first-line systemic; takes 3-6 months to work
• Oral pioglitazone 15 mg/day - some evidence in lichen planopilaris
• Doxycycline 100 mg BD - anti-inflammatory; third-line

Nail Lichen Planus

• Intralesional triamcinolone 5-10 mg/mL injected into nail matrix/bed - most effective
• Systemic treatment (methotrexate, acitretin, hydroxychloroquine) when nail LP is part of generalized disease
• Act early to prevent permanent nail loss (pterygium formation, anonychia)

Anogenital Lichen Planus

• Potent CS ointment (clobetasol 0.05%) - 3-month course, then taper to moderately potent
• Vaginal suppositories (hydrocortisone acetate 200-300 mg nightly) for vaginal disease
• Use vaginal dilators to prevent stenosis; surgery may be needed for adhesions
• Long-term follow-up mandatory - SCC risk ~2.4%

Monitoring Summary