Dermatovenerology. Lichen planus (most important)

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Dermatovenerology. Lichen planus (most important)

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LECTURE number 9. Lichen planus

Lichen planus is a non-infectious inflammatory disease characterized by the appearance of itchy flat polygonal papules on the skin and mucous membranes. The course of the disease can be both acute and chronic.

Etiology. For this form of dermatosis, the etiology is not clear.

Pathogenesis. Currently, the pathogenesis of this dermatosis is considered as a complex participation of the following factors: infectious (viral), neuroendocrine, genetic, immune (graft-versus-host reaction), toxic-allergic (toxic effects of drugs - preparations of gold, arsenic, mercury, quinine, its derivatives , ftivazid, PAS, tetracycline), autointoxication caused by diseases of the gastrointestinal tract, diabetes mellitus, liver dysfunction, including chronic hepatitis C).

Clinic. The typical form of lichen planus is characterized by a monomorphic rash in the form of small, flat, shiny (especially in side lighting), polygonal (polygonal) papules, not prone to peripheral growth. The color of the elements is reddish-pink with a characteristic lilac or purple tint. In the center of the papules there is a small umbilical depression. On the surface of the nodules, one can find Wickham's reticulum, pathognomonic for this dermatosis, characterized by a combination of white or grayish dots and stripes. Wickham's reticulum is clearly visible under a magnifying glass after lubricating the surface of the affected area with vegetable or petroleum jelly. The formation of the mesh is explained by the uneven thickening of the granular layer. Eruptive elements can be grouped to form small plaques covered with scales, along the periphery of which new, isolated small papules appear, which is explained by the jerky nature of the appearance of rashes in this dermatosis.

Of the subjective symptoms in most patients, intense itching is noted, often general anxiety.

Typical rashes of lichen planus are usually localized on the flexor surfaces of the forearms and wrist joints, the anterior surfaces of the legs, in the sacrum, in men - on the penis.

On the red border of the lips (more often on the lower one), small, slightly flaky, purple flat plaques are formed, on the surface of which, when wetted with water or lubricated with oil, a grayish-white mesh is revealed.

The change in the nail plates with lichen planus is characterized by the formation of furrows, depressions, and areas of turbidity. Nails can become thinner and even partially or completely destroyed. The nail plates of the big toes are most often affected.

In addition to the classical form, many atypical forms of lichen planus have been described. Atypical forms of the disease include: annular, warty (verrucous), pemphigoid, atrophic, erosive-ulcerative, follicular.

The ring-shaped form of lichen planus is characterized by the presence of rashes in the form of rings. Separate papules and plaques, undergoing resolution in the center, form small rings, the central part of which may have a brown color.

The warty (verrucous) form is diagnosed with the formation (usually on the lower extremities) of purple or brownish-red plaques that rise significantly above the level of healthy skin, with an uneven surface, covered with massive horny layers. On the periphery of the plaques, individual typical papules of lichen planus can be found.

The pemphigoid (bullous) form is characterized by the appearance of blisters on papules and plaques of lichen planus, as well as on erythematous areas and unchanged skin. With this form of the disease, the general condition of the patient is often disturbed. When the rash resolves, atrophy and hyperpigmentation may remain. With the localization of elements on the scalp, the development of cicatricial alopecia is possible. Pemphigoid form of lichen planus can act as a paraneoplastic syndrome.

The atrophic form of lichen planus is diagnosed in cases where atrophy develops after resolution of primary lesions.

The erosive-ulcerative form of lichen planus is characterized by the formation of erosive-ulcerative defects on the mucous membrane of the mouth (cheeks, gums, red border of the lips) or on the skin of the legs. Erosions or small ulcers of irregular or rounded outlines with a pinkish-red surface, at the base and along their periphery, a sharply limited plaque infiltrate can persist for quite a long time.

The follicular form of lichen planus occurs in two variants: either in the form of follicular and perifollicular papules, or in the form of scarring alopecia of the scalp, as well as non-scarring alopecia of the armpits and pubis.

Lichen planus exists for a long time, many months, sometimes years. Starting acutely or subacutely, the skin lesion progresses for the first time, which is expressed in the appearance of new elements. Then comes the stationary period, usually lasting several months. Following this, the lesion begins to gradually resolve, and hyperpigmentation remains in place of papules and plaques. Acute lichen planus can regress relatively quickly, but more often becomes chronic.

Pathomorphology. In the typical form of lichen planus, hyperkeratosis, thickening of the granular layer (focal granulosis), acanthosis (elongated interpapillary processes pointed downwards - a saw-like symptom), and vacuolar degeneration of the cells of the basal layer of the epidermis are observed. The strip-like infiltrate in the upper part of the dermis is closely adjacent to the epidermis, blurring its lower border. The infiltrate contains lymphocytes and histiocytes. At the border between the epidermis and dermis, Siwatt bodies are visible - degenerated keratinocytes. Sometimes there are gap-like spaces between the epidermis and dermis.

Diagnostics. In typical cases, making a diagnosis of lichen planus is not difficult. The characteristic coloring of the elements with a lilac-pearl shade, the polygonal outlines of flat papules with an umbilical depression in the center, the presence of Wickham's mesh, the localization of lesions on the flexor surface of the forearms and often on the mucous membrane of the oral cavity and genital organs - all this almost accurately allows us to make a diagnosis of lichen planus , without even resorting to histological examination.

Treatment. Depending on the clinical form of the disease, the prevalence of the pathological process and the localization of the lesions, various treatment options for lichen planus are carried out.

1. Therapy with antimalarial drugs.

2. Therapy with aromatic retinoids (derivatives of acitretin).

3. PUVA therapy (with common forms).

4. Corticosteroid therapy (short courses in acute generalized forms).

5. Therapy with cyclosporine A (with resistance to other therapy options and generalized forms).

6. Treatment with antidepressants, tranquilizers, anxiolytics.

7. Hyposensitizing therapy with calcium preparations and antihistamines.

8. Treatment of concomitant diseases that complicate the course of dermatosis.

Outwardly, antipruritic shaken mixtures with menthol and anesthesin, corticosteroid creams and ointments are prescribed (possibly under an occlusive dressing). Large and verrucous lesions are treated with corticosteroids or cryodestruction or laser therapy is performed. In severe lesions of the oral mucosa, rinsing with a solution of cyclosporine or a corticosteroid is prescribed.

Author: Sitkalieva E.V.

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