Drug-Induced Lichen Planus

Drug-Induced Lichen Planus

Article
Skin Care
Diseases & Conditions
Contributed byKrish Tangella MD, MBAMay 22, 2018

What are the other Names for this Condition? (Also known as/Synonyms)

  • Drug-Induced LP (Lichen Planus)
  • Lichenoid Drug Eruption (LDE)
  • Medication-Induced Lichen Planus

What is Drug-Induced Lichen Planus? (Definition/Background Information)

  • Lichen Planus (LP) is a common, benign condition of generally unknown cause affecting the skin and mucus membranes. Classically, Lichen Planus skin lesions have been described as papule, purple, polygonal, and pruritus - the “4 P’s”. These can occur anywhere in the body and mouth
  • Drug-Induced Lichen Planus is an uncommon condition that occurs due to certain medications (side effect). It is also known as Lichenoid Drug Eruption (LDE)
  • It mainly manifests as skin lesions on the arms, legs, and trunk. Though, in many individuals the condition is asymptomatic, in some there may be itching from lesions on the skin and pain from lesions in the mouth
  • The primary treatment for Drug-Induced Lichen Planus in symptomatic individuals is discontinuation or stoppage of the offending medication, including the use of topical steroidal creams. The prognosis of Drug-Induced Lichen Planus is generally good

Who gets Drug-Induced Lichen Planus? (Age and Sex Distribution)

  • Drug-Induced Lichen Planus is an infrequently arising skin condition caused by a variety of medications (that are administered for other underlying conditions). Any individual may be at risk of Drug-Induced Lichen Planus
  • It can affect both males and females
  • The condition occurs worldwide; individuals of all racial and ethnic background may be affected

What are the Risk Factors for Drug-Induced Lichen Planus? (Predisposing Factors)

The key risk factor for Drug-Induced Lichen Planus is the administration of certain drugs that cause the condition as a side effect. The common categories of drugs observed to induce this condition include:

  • Antimalarial drugs
  • Angiotensin-converting enzymes (ACE) inhibitors
  • Beta blocker drugs
  • Thiazide diuretics
  • Antifungal medications
  • Anti-seizure medications
  • Antiretroviral therapy drugs (for HIV infection)
  • Allopurinol (administered for gout)

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases ones chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Drug-Induced Lichen Planus? (Etiology)

  • Drug-Induced Lichen Planus occurs as an adverse reaction to certain medications that are taken for various conditions. The offending drug potentially causes an abnormal cell-mediated immune response in the body
  • This results in the formation of lesions on the skin and mucus membranes of the body
    • Oral lesions can occur with antifungal medications, antiseizure medications, antiretroviral therapy drugs, and allopurinol
    • Skin lesions may also occur due to antimalarial medications, ACE inhibitors, beta blockers, and thiazide diuretics    

Sometimes, the appearance of signs and symptoms due to the drug may not be observed immediately

What are the Signs and Symptoms of Drug-Induced Lichen Planus?

Drug-Induced Lichen Planus may have a slow onset. In some cases, the appearance of the signs and symptoms is not immediate after commencement of the drug; it may take weeks, months, or even years for them to develop.

In many individuals, apart from itching, there may not be any significant signs and symptoms due to Drug-Induced Lichen Planus. In others, the following may be observed:

  • Itchy skin lesions that can occur as groups anywhere on the body
  • Most frequently, the lesions are found in the arms, legs, chest, back, and mouth
  • Nails may be malformed, in some cases
  • Lesions range in size from 1-10 mm
  • Lesions in the mucus membranes of the mouth appear as white patches and are painful; these may occasionally ulcerate and bleed
  • The mouth ulcers can make it difficult to eat, drink, or even speak
  • The skin may become rough, discolored, and thick, due to frequent itching and scaling of the skin

The severity of Drug-Induced Lichen Planus may vary; it is difficult to predict who gets mild or severe symptoms.

How is Drug-Induced Lichen Planus Diagnosed?

The following are the diagnostic methods and tests that may be used for Drug-Induced Lichen Planus:

  • A complete physical examination and a thorough medical history (which includes the use of any drugs) are very important
  • Dermoscopy: Dermoscopy is a diagnostic tool where a dermatologist examines the skin using a special magnified lens
  • Skin or tissue biopsy: A skin or tissue biopsy is performed and sent to a laboratory for a pathological examination, who examines the biopsy under a microscope. After putting together clinical findings, special studies on tissues (if needed) and with microscope findings, the pathologist arrives at a definitive diagnosis. A biopsy is performed to rule out other similar conditions

Note: In most cases, based on the signs and symptoms, a diagnosis can be made by the dermatologist through a physical examination and medical history study, without resorting to a biopsy.

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Drug-Induced Lichen Planus?

Complications of Drug-Induced Lichen Planus may include:

  • Bacterial and fungal infections: Lichen Planus may cause continuous itching and scaling of the skin, which creates skin moistness, providing a suitable environment for bacteria and fungi to grow and thrive
  • Rarely, squamous cell carcinoma can develop from the lesions
  • The lesions can last for years resulting in self-image issues, emotional stress, and psychological trauma (depression) in some individuals

How is Drug-Induced Lichen Planus Treated?

In most individuals, Lichen Planus is a self-limiting disorder that requires no treatment. The condition subsides and goes away on its own. The symptoms are mild and symptomatic treatment is also not required.

The treatment of Drug-Induced Lichen Planus may include:

  • Discontinuing the medication responsible for the side effect may result in a cure
  • For mild skin conditions, washing with mild (antibacterial) soap and applying warm compress, may be advised
  • Use of topical steroidal creams and lotions
  • Administration of systemic steroids
  • Oral steroids for severe itching, painful oral lesions, pain while swallowing, and cosmetic issues
  • Immunosuppressive therapy, such as using cyclosporine (mouthwash for oral lesions), when the condition does not respond to steroidal treatments
  • Photo-chemotherapy can be used in generalized Lichen Planus and those that do not respond to medications
  • Systemic retinoids in case of severe signs and symptoms
  • Providing reassurance and helping with feelings of stress and anxiety
  • Follow-up care with regular screening and checkups are important, since the condition may last for many months and years

Note: If any of the prescribed treatment medication or methods cause new stinging or burning symptoms, then it is important to discontinue the medication or method and immediately inform the healthcare provider.

A few self-care tips and home remedies that may prevent aggravation of the condition may include:

  • Completely avoid scratching the affected areas
  • A comfortable, cool bath may help soothe the skin; but, avoid excessive washing and scrubbing of the skin
  • Wear smooth cotton clothes
  • Use only mild perfumes, soaps, and detergents
  • Drinking lots of water or fluids

How can Drug-Induced Lichen Planus be Prevented?

Currently, it is not possible to prevent Drug-Induced Lichen Planus.

  • Stopping the medication causing the condition as early as possible is important. The healthcare provider may prescribe alternative medications to treat the existing, underlying condition
  • Periodic monitoring or follow-up of the condition with the healthcare provider is recommended

What is the Prognosis of Drug-Induced Lichen Planus? (Outcomes/Resolutions)

  • Drug-Induced Lichen Planus may be asymptomatic in some individuals. Such individuals do not require any treatment; reassurance and periodic observance may be sufficient treatment
  • However, many individuals have mild symptoms, and the condition may spontaneously get better without any treatment. The lesions may completely disappear over time. The prognosis is excellent in such cases
  • In some individuals, the symptoms may appear, subside, and then recur with time. Besides, ulcerative lesions are difficult to treat. In such cases, symptomatic treatment may be provided to improve the quality of life

Additional and Relevant Useful Information for Drug-Induced Lichen Planus:

Cleaning the skin too hard with strong chemicals or soaps may aggravate the skin condition. Care must be taken avoid strong soaps and chemicals that can potentially worsen the condition.

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Krish Tangella MD, MBA picture
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Krish Tangella MD, MBA

Pathology, Medical Editorial Board, DoveMed Team

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