Lichen Planus: Advances in Diagnosis and Treatment

New data, including a primary study, clarify noninvasive diagnostic markers and a stepped therapeutic pathway for lichen planus (LP), supporting earlier recognition and structured escalation to shorten time to effective therapy and reduce avoidable morbidity.

Historically, clinicians relied primarily on clinical inspection and histopathology to define LP and its variants, which could delay variant recognition and management. Current evidence shifts practice toward earlier, targeted visualization and predefined treatment sequencing to better guide biopsy decisions and initial therapy choice—translating to faster, more precise care.

Dermoscopic evaluation now offers superior lesion visualization and clearer differentiation of LP variants compared with routine inspection. In the cited primary study (PubMed 38982032), investigators reported improved visualization of characteristic features—most commonly Wickham striae and a purple‑violet background—supporting dermoscopy's role in identifying LP and helping to triage biopsies. Biopsy remains indicated for atypical, persistent, or treatment‑resistant presentations.

First‑line therapy continues to be high‑potency topical corticosteroids for most cutaneous and mucosal LP variants, typically as an induction course (eg, clobetasol 0.05% once daily for 2–4 weeks) followed by a taper to maintenance application 2–3 times weekly as symptoms permit.

Alternatives for steroid‑refractory lesions or steroid‑sensitive sites include topical calcineurin inhibitors (eg, tacrolimus 0.1% twice daily) and intralesional steroid injections (eg, triamcinolone 5–10 mg/mL every 4–6 weeks); each option carries distinct adverse‑effect profiles such as skin atrophy or mucosal irritation. Escalation beyond topical or procedural measures is warranted when local therapies fail, lesions are functionally impairing, or steroid adverse effects limit use.

For refractory or extensive disease, the cited primary study reported clinical benefit with methotrexate in the treated cohort, though the findings reflect that study's sample size and scope. Other systemic agents described in case series include cyclosporine and various immunomodulators; targeted biologics and small molecules remain under active investigation. '

And so it's important to consider systemic therapy for widespread skin involvement, disabling mucosal disease, or steroid dependence, with baseline and periodic CBC and LFT monitoring and clinical reassessment over 8–12 weeks to judge response.

Key Takeaways:

• Dermoscopy improves variant recognition and can help triage biopsies by highlighting patterns such as Wickham striae and a purple‑violet background.
• Patients with ambiguous cutaneous or mucosal lesions and those not controlled with topical therapy.
• Continue to prefer high‑potency topical corticosteroids as first‑line; reserve systemic or biologic therapy for refractory or disabling cases and apply defined monitoring protocols.

FAQs:

1. When should dermoscopy be used in the evaluation of suspected lichen planus?
Dermoscopy is recommended at the initial assessment stage to enhance visualization of hallmark features such as Wickham striae and a purple‑violet hue. It improves diagnostic accuracy, aids in variant recognition, and helps determine whether biopsy is necessary—particularly in ambiguous or atypical cases.

2. What is the preferred first-line treatment for cutaneous or mucosal lichen planus?
High-potency topical corticosteroids, such as clobetasol 0.05% once daily for 2–4 weeks, remain first-line. If effective, treatment should taper to a maintenance schedule (e.g., 2–3 times weekly) based on symptom control.

3. When should systemic therapy be considered for lichen planus?
Systemic therapy is appropriate for patients with refractory lesions, widespread skin involvement, disabling mucosal disease, or when topical treatments are limited by adverse effects. Methotrexate, supported by recent clinical data, is among the agents used, with others including cyclosporine and investigational biologics.

4. What monitoring is required when initiating systemic treatment for LP?
Baseline and periodic monitoring—especially complete blood count (CBC) and liver function tests (LFTs)—is essential. Clinical reassessment should occur at 8–12 weeks to evaluate response and adjust therapy accordingly.