Lichen Planus; Causes, Symptoms, Diagnosis, Treatment, Natural Remedies

Lichen planus








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Lichen planus (LP) is a disease characterized by itchy reddish-purple polygon-shaped skin lesions on the lower back, wrists, and ankles. It may also present with a burning sensation in the mouth, and a lattice-like network of white lines near sites of erosion (Wickham striae). 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.

Causes of Lichen Planus

The cause of lichen planus is unknown, but it is not contagious and does not involve any known pathogen. It is thought to be a T cell mediated autoimmune reaction (where the body’s immune system targets its own tissues). This autoimmune process triggers apoptosis of the epithelial cells. Several cytokines are involved in lichen planus, including tumor necrosis factor alpha, interferon gamma, interleukin-1 alpha, interleukin 6, and interleukin 8. This autoimmune, T cell mediated, process is thought to be in response to some antigenicchange in the oral mucosa, but a specific antigen has not been identified.

Where a causal or triggering agent is identified, this is termed a lichenoid reaction rather than lichen planus. These may include:

  • Drug reactions, with the most common inducers including gold salts, beta blockers, traditional antimalarials (e.g., quinine), thiazide diuretics, furosemide, spironolactone, metforminand penicillamine.
  • Reactions to amalgam (metal alloys) fillings (or when they are removed/replaced),
  • Graft-versus-host disease lesions, which chronic lichenoid lesions seen on the palms, soles, face and upper trunk after several months.
  • Hepatitis, specifically hepatitis B and hepatitis C infection, and primary biliary cirrhosis.

It has been suggested that lichen planus may respond to stress, where lesions may present during times of stress. Lichen planus can be part of Grinspan’s syndrome.

It has also been suggested that mercury exposure may contribute to lichen planus.

Symptoms of Lichen Planus

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.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.

Cutaneous lichen planus

Variants of cutaneous lichen planus are distinguished based upon the appearance of the lesions and/or their distribution. Lesions can affect the:

  • Extremities (face, dorsal hands, arms, and nape of neck). This is more common in Middle Eastern countries in spring and summer, where sunlight appears to have a precipitating effect.
  • Palms and soles
  • Intertriginous areas of the skin. This is also known as “Inverse lichen planus.
  • Nails characterized by irregular longitudinal grooving and ridging of the nail plate, thinning of the nail plate, pterygium formation, shedding of the nail plate with atrophy of the nail bed, subungual keratosis, longitudinal erthronychia (red streaks), and subungual hyperpigmentation. A sand-papered appearance is present in around 10% of individuals with nail lichen planus.
  • 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.

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.
  • 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 sorrheic dermatitis-like eruption on the scalp and face; also palmo plantar keratosis has been reported
  • Lichenoid keratoses (also known as “Benign lichenoid keratosis,” and “Solitary lichen planus”) is a cutaneous condition characterized by brown to red scaling maculopapules, found on sun-exposed skin of extremities. Restated, this is a cutaneous condition usually characterized by a solitary dusky-red to violaceous papular skin lesion.
  • Lichenoid dermatitis represents a wide range of cutaneous disorders characterized by lichen planus-like skin lesions.
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Mucosal lichen planus

Lichen planus on the lips and the lateral border of the tongue

Lichen planus affecting mucosal surfaces may have one lesion or be multifocal.Examples of lichen planus affecting mucosal surfaces include

  • Esophageal lichen planus, affecting the esophageal mucosa. This can present with difficulty or pain when swallowing due to 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.
  • 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. Symptoms may include lower urinary tract symptoms associated with stenosis of the urethra, painful sexual intercourse, and itching. In females, Vulvovaginal-gingival syndrome, is severe and distinct variant affecting the vulva, vagina, and gums, with complications including scarring, vaginal stricture formation, or vulva destruction. The corresponding syndrome in males, affecting the glans penis and gums, is the peno-gingival syndrome. It is associated with HLA-DQB1.

Mouth

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. This may occur in combination with other variants of lichen planus. Six clinical forms of oral lichen planus are recognized

  • Reticular, the most common presentation of oral lichen planus, is characterised by the net-like or spider web-like appearance of lacy white lines, oral variants of Wickham’s straiae. This is usually asymptomatic.
  • Erosive/ulcerative, the second most common form of oral lichen planus,  is characterised by oral ulcers presenting with persistent, irregular areas of redness, ulcerations and erosions covered with a yellow slough. 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). This may be the initial or only sign of the condition.
  • Papular, with white papules.
  • Plaque-like appearing as a white patch which may resemble leukoplakia.
  • Atrophic, appearing as areas. Atrophic oral lichen planus may also manifest as desquamative gingivitis.
  • Bullous, appearing as fluid-filled vesicles which project from the surface.

These types often coexist in the same individual. Oral lichen planus tends to present bilaterally as mostly white lesions on the inner cheek, 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.

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.When symptoms arise, they are most commonly associated with the atrophic and ulcerative subtypes. These symptoms can include a burning sensation to severe pain.Lichen planus, particularly when concomitant oral or genital lesions occur, significantly affects patients’ quality of life.

Diagnosis of Lichen Planus

Lichen planus lesions are diagnosed clinically by their “lichen-like” appearance. A biopsy can be used to rule out conditions that may resemble lichen planus, and can pick up any secondary malignancies.

Histopathology

Lichen planus has a unique microscopic appearance that is similar between cutaneous, mucosal and oral. A Periodic acid-Schiff stain of the biopsy may be used to visualise the specimen. Histological features seen include

  • thickening of the stratum corneum both with nuclei present (parakeratosis) and without (orthokeratosis). Parakeratosis is more common in oral variants of lichen planus.
  • thickening of the stratum granulosum
  • thickening of the stratum spinosum (acanthosis) with formation of colloid bodies (also known as Civatte bodies, Sabouraud bodies) that may stretch down to the lamina propria.
  • liquefactive degeneration of the stratum basale, with separation from the underlying lamina propria, as a result of desmosome loss, creating small spaces (Max Joseph spaces).
  • Infiltration of T cells in a band-like pattern into the dermis “hugging” the basal layer.
  • Development of a “saw-tooth” appearance of the rete pegs, which is much more common in non-oral forms of lichen planus.

Differential diagnosis

  • Other oral vesiculo-ulcerative conditions such as Pemphigus vulgaris and Benign mucous membrane pemphigoid
  • Lupus erythematosus, with lesions more commonly occur on the palate and appear as centrally ulcerated or erythematous with radiating white striae. In contrast, OLP and lichenoid reactions rarely occur on the palate, and the striae are randomly arranged rather than radial.
  • Chronic ulcerative stomatitis
  • Frictional keratosis and Morsicatio buccarum (chronic cheek biting)
  • Oral leukoplakia
  • Oral candidiasis

Effective Natural Remedies To Treat Lichen Planus

Since there is no direct cure for lichen planus, focus on reducing the symptoms. Apply turmeric paste, coconut oil, or ginger juice on the affected areas; drink valerian or ginger tea and aloe vera juice; take an oatmeal bath once a week; try oil pulling with coconut oil; stick to a healthy diet rich in vitamins A, B9, and D; and expose your skin to sunlight once a day.

Lichen planus is a non-infectious inflammation that appears on different areas of the body. It is characterized by an itchy, reddish-purple rash. The most affected areas are arms, legs, mouth, vagina, vulva, penis, and the scalp.

The exact causes of lichen planus are largely unknown, but a few experts claim the skin disease is an autoimmune disorder or caused by viral infections like Hepatitis C. It affects 2% of the world’s population and is mostly seen in people above 40 years of age, chiefly females. Lichen planus on the skin can clear up in about 6 to 9 months. But it could leave permanent marks on other parts of the body and also take longer to heal. Though there is no cure for lichen planus, there are things you can do at home to reduce the severity of the symptoms.

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1. Apply Turmeric On Affected Areas

Turmeric is an age-old remedy for any skin issue. And for good reason! It has been found to be anti-inflammatory and antibacterial. And it’s packed with antioxidants. This is due to curcumin, a key ingredient in turmeric.

One study revealed, in the case of oral lichen planus, applying turmeric ointment on the mouth sores for 3 months removed the signs completely in patients.

There was visible improvement in oral lichen planus in just 10 days of having turmeric.

How To Use Turmeric For Lichen Planus

  • For lichen planus on the skin, apply a paste of turmeric powder and water on the affected areas and rinse it off after 15 minutes.
  • For oral lichen planus, the above-mentioned study made a turmeric ointment using 10 parts of alcohol to 1 part powder.
  • Add turmeric powder to your dishes.

2. Use Tea Tree Oil Mouthwash

Tea tree oil is a powerhouse of goodness. It has proven beneficial for treating various skin conditions including acne, psoriasis, and eczema.2 This is because of its anti-inflammatory and antimicrobial properties, both useful for any skin-related condition. The same properties make it good for treating mouth sores associated with oral lichen planus. Oral hygiene is an important part of the treatment.

DIY Tea Tree Oil Mouthwash 

Ingredients

  • 2 tablespoons tea tree essential oil
  • 2 tablespoons baking soda
  • 2 tablespoons peppermint essential oil
  • 1/2 cup water

Method

  • Mix all the ingredients and store in a glass jar.
  • Rinse your mouth with this wash once a day.

3. Apply Ginger Juice On Affected Areas

Ginger is another ancient remedy to keep inflammation at bay. Studies have proven that ginger has anti-inflammatory and antioxidant benefits.3 But that’s not all. Ginger is also a great antihistamine – used for treating allergies. Sometimes, an allergic reaction could cause lichen planus on certain parts of the body, and ginger can help reduce the signs of the allergy.

How To Use Ginger  

  • Apply ginger juice on the affected areas.
  • Drink ginger tea regularly.

4. Use Aloe Vera Juice And Gel

Aloe vera has a truckload of benefits, a reason why the Japanese refer to the plant as “no need for a doctor.” Numerous studies reveal that aloe vera is great for treating inflammation, mouth ulcers, wounds, and burns.

In 9 months, drinking aloe vera juice and applying aloe vera gel can completely cure lichen planus.

One study found out aloe vera reduced all the symptoms of lichen planus, including burning sensation, severe pain, and skin lesions. In 9 months, the patients were symptom-free.

How To Use Aloe Vera

  • Start every morning with a glass of aloe vera juice.
  • Apply aloe vera gel on the affected areas of the skin.
  • For oral lichen planus, aloe vera mouthwash can be beneficial.

 5. Take An Oatmeal Bath

There’s a reason a lot of people love taking an oatmeal bath. Oatmeal has been found to be great for the skin. Its natural exfoliating and cleansing properties, along with its effect against inflammation, can improve the symptoms of lichen planus. It can also give relief to itchy skin.

How To Use Oatmeal

  • Take an oatmeal bath once or twice a week.
  • Apply a mixture of oats and water directly on the affected areas.

6. Drink Valerian Tea

Valerian is a popular sedative herb. It is used to treat anxiety and sleep-related issues. A lichen planus flare-up could be triggered by stress, and this herb can provide a calming effect on the mind and help in stress management.

How To Use Valerian

  • Drink a cup of valerian tea a few times a week.

7. Try Oil Pulling With Coconut Oil

There hasn’t been any study to establish the healing effect of coconut oil on lichen planus yet. But many patients have reported significant improvement to complete cure after oil pulling with coconut oil or applying coconut oil on the affected area.

8. Eat Foods Rich In Vitamin A And B9

It has been found that people with lichen planus have a low level of folate or vitamin B9. You can find folate in dark green leafy vegetables, lentils, beans, citrus fruits, and avocado.

As far back as the 1970s, clinical studies found that applying retinoic acid (vitamin A acid) on lichen planus in the mouth and the genitals helped heal the condition. It is possible that having enough vitamin A in the diet can reduce the symptoms. Foods rich in vitamin A include beef liver, carrots, and leafy greens like kale and spinach.

9. Spend Time In The Sun

A study and a case report have suggested that oral lichen planus is linked with a vitamin D deficiency. This sunshine vitamin is linked with our immunity, and we know that some cases of lichen planus are an autoimmune reaction.14 15 Spend some time in the sun, exposing the affected areas to sunlight, and eat vitamin D foods like tuna or salmon and egg yolks.

Things You Need To Follow If You Have Lichen Planus

  • If you are having an itchy bout, cool compresses can provide immediate relief. Avoid scratching.
  • Remember, if you have oral lichen planus, be strong in your oral hygiene game.
  • Avoid spicy, acidic, and hard foods.
  • Eat plenty of veggies and fruits. Your body needs all the vitamins and minerals during a flare-up, especially vitamin B9 or folate.
  • Stay clear from drinking alcohol and smoking.
  • If you have genital lichen planus, don’t use soap to clean up. Just water is fine.
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We know it’s difficult to cope with lichen planus. But be strong and try to follow a healthy and stress-free life.

Ayurveda’s Approach to Healthy Skin

In Ayurveda, we work to actively promote health primarily by what we put into, versus onto, our bodies. Ayurveda, which is comprised of the words “Ayur,” meaning “life,” and “Veda,” meaning “knowledge,” is known as the science of life. As such, Ayurveda truly touches upon all of the myriad aspects of life that make it as full and rich as it is. From digestion to psychology to sexual health to spirituality to skincare, Ayurveda, as a spiritual science of life, really covers it all, with incredible precision, clarity, and insight.

In the modern era, we work so hard to cover up our skin with various products, from moisturizers to toners to serums to lotions and creams that often deliver limited results, at best. At worst, these products, because they are all chemically based, cause our skin to react, which means we resort to wearing to makeup, which then further ruins our skin, creating a vicious cycle.

Causes of Itchy Armpits And Easy Home Remedies

And digestion is not just something that happens in the stomach only. Skin is the largest organ of the body and is more vulnerable to disease, infection, injury, and imbalance than any other bodily structure. When we don’t digest our food properly, it not only affects our body internally; it is also reflected in the quality of our skin. That is why we focus so much in Ayurveda on avoiding those foods that cannot be easily digested, such as the incompatible combinations listed above.

I can clearly see how my skin and digestion have improved since I stopped eating incompatible foods in particular.

3. Go To Sleep and Wake Up Early

Sleep is considered one of the three pillars of health, according to Ayurveda. The body actually heals itself as we sleep at night, ideally by 10pm. When we miss the ideal time for sleep and try to compensate by sleeping excessively during the day, our health suffers, and it shows up adversely on our skin. Excess daytime sleep is also one of the causative factors of skin-related conditions.

Going to sleep and waking up early, between 4-6am, has changed my life in countless ways, giving me tremendous willpower, insight, and clarity, in addition to better skin.

4. Stop Sunbathing

This one should come as no surprise. Ayurveda is all about addressing the root causes of why health problems manifest in the first place. No matter how much sunscreen you may liberally apply to your face and body, excess sun exposure will definitely damage your skin. It is therefore essential to protect yourself with a hat and/or sunglasses. Whenever you feel the temptation to soak in the sun, ask yourself, is it really necessary?

5. Do Something to be of Service, Without Any Strings Attached

Mental stress is a huge causative factor for skin problems. From Ayurveda, we learn that Sadvritta, a noble code of social and moral behavior, is an essential part of health that is just as important as what we put into and onto our bodies. So much of our stress in life comes from the kinds of relationships we have with others, as well as our own worries about our current and/or future security, whether that be physical, emotional, financial, etc.

Whenever we are able to step out of our own suffering enough to help another, we are automatically filled with joy. Even if all we can do is spend an hour a week serving soup in a soup kitchen, that one hour can help us connect with our inherent goodness, bringing out our inner glow and light of Sattva (an auspicious, peaceful, noble, and joyful state of mind that Ayurveda psychology teaches is our true state).

References

  1.  “Oral lichen planus”Anais brasileiros de dermatologia86 (4): 633–41; quiz 642–43. doi:10.1590/s0365-05962011000400002PMID 21987126.
  2. “Pathophysiology, etiologic factors, and clinical management of oral lichen planus, part I: facts and controversies”Clinics in Dermatology28 (1): 100–08. doi:10.1016/j.clindermatol.2009.03.004.
  3.  Di Lernia, Vito (2016-07-01). “Targeting the IFN-γ/CXCL10 pathway in lichen planus”Medical Hypotheses92: 60–61. doi:10.1016/j.mehy.2016.04.042.
  4. Murphy, Ruth (2012-02-15). “Interventions for erosive lichen planus affecting mucosal sites”Cochrane Database of Systematic Reviewsdoi:10.1002/14651858.CD008092.pub2ISSN 1465-1858.

Lichen planus

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