Lichen Planus: Underrecognized Skin Disorder

Andrew Siegel MD     11/13/2021

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Recent entries have concerned skin issues—molluscum contagiosum and shingles—so to continue on that theme, today’s entry is about a skin dermatosis that can present with genital lesions.

A Brief Diversion on Real Lichens

A recent NY Times article reviewed the details of lichens, one of earliest land-dwelling forms of life that are neither plant nor animal.  They are widespread around the world, including a presence in Antarctica and deserts.  They are fascinating composite symbiotic organisms that often include a fungus, an alga and a bacterium. The alga within the fungus uses photosynthesis that produces sugars that sustain the fungus. These life forms are vital components of our ecosystem.

Green lichen, attribution: Umberto Salvagnin from Italy, CC BY 2.0 <https://creativecommons.org/licenses/by/2.0&gt;, via Wikimedia Commons, image unmodified

LICHEN PLANUS

Lichen planus (LP) is a dermatological disorder that can present with genital lesions and thus with a patient who seeks urological or gynecological care.  The term “lichen planus” derives from the Greek word leichen (tree moss) and the Latin word planus (flat).  It is a non-sexually transmitted chronic muco-cutaneous (present in mucous membranes and skin) disorder that causes skin lesions that may involve the genitals, mouth, skin, nails, and scalp. Its prevalence is 1-2% of the adult population, generally age 30-60, but may occur at any age and is more common in females than males.

LP is thought to be an autoimmune disease in which cytotoxic T-cells attack and damage skin or mucosal cells, resulting in the characteristic skin or mucosal lesions. Because of its autoimmune basis, when LP is diagnosed it is important to rule out other possibly more systemic autoimmune diseases, generally done through bloodwork ordered by a rheumatologist.

The two main types of lichen planus are oral lichen planus (OLP) and genital lichen planus (GLP).  The oral type tends to be more chronic than the genital type, is less responsive to management efforts, and has a small risk of malignant transformation. The genital subtype can be particularly psychologically distressing, but it tends to be more of an acute issue that generally will heal over time.

OLP typically causes fine, whitish-gray thread-like, radiating, interlacing, velvety, linear papules (bumps) and plaques at one extreme to severe erosion and scarring at the other extreme.  The clinical presentations include the following: reticular (netlike); erosive (surface destruction); atrophic; plaque-like (patch-like); papular (raised); and bullous (blister-like). Small and accessible erosive lesions located on the gums and cheeks can be managed by the use of an anti-inflammatory in adherent paste form, or alternatively, in the form of a custom tray. The skin lesions of LP are 5 descriptors beginning with the letter “P”: Purple, polygonal, pruritic (itchy), papules and plaque.

Male GLP typically manifests with reddish-brown papules and plaques on the shaft of the penis and sometimes an erosive variant that involves the head of the penis. It may cause itching, burning, and sexual issues.  When it involves the penis and mouth it is known as peno-gingival syndrome.  A consequence of GLP in the uncircumcised population may be phimosis, a condition in which the foreskin cannot be retracted properly.

Female GLP manifests with lesions of the vulva and vagina, which may cause soreness or pain, itching, bleeding, discharge, and painful intercourse.  When erosive disease is progressive it may lead to scarring of the vulva, labial changes and vaginal shortening. Females may present with vulvo-vaginal gingival syndrome, with lesions involving the vulva, vagina, and mouth. 

When GLP causes erosive changes, it can be managed with either potent topical steroids such as Clobetasol ointment or topical immuno-suppressive agents, retinoids, and immunomodulators.  Drugs used systemically are thalidomide, metronidazole, griseofulvin, and hydroxychloroquine, some retinoids and corticosteroids.

Wishing you the best of health,

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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro AreaInside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, the largest urology practice in the United States.  He is the co-founder of PelvicRx and Private Gym.  His latest book is Prostate Cancer 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families. 



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Video trailer for Prostate Cancer 20/20

Preview of Prostate Cancer 20/20

Andrew Siegel MD Amazon author page

PROSTATE CANCER 20/20 is now available at Audible, iTunes and Amazon as an audiobook read by the author (just over 6 hours). 

Dr. Siegel’s other books:

FINDING YOUR OWN FOUNTAIN OF YOUTH: The Essential Guide to Maximizing Health, Wellness, Fitness and Longevity

PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food

MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health

Video on THE KEGEL FIX

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