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Chapter 8: Lichen Planus

INTRODUCTION

KEY POINTS

  • Lichen planus is an inflammatory disorder that varies in clinical presentation across skin colors and also has numerous unique variants some of which are more common in darker skin populations.

  • Classic lichen planus morphology in all skin colors tends to be flat, polygonal papules and plaques. However, the color varies and tends to be pink to red in lighter skin in contrast to the classic presentation in darker skin, which is typically purple to violaceous or brown to gray.

  • Variants of lichen planus that can be seen more commonly in darker skin colors include annular, actinic, and follicular lichen planus.

  • Lichen planus can also resolve with significant postinflammatory pigment alteration, particularly in those with darker skin.

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FIGURE 8-1.

Flat-topped, purple, polygonal scaly papules on the trunk and posterior upper extremity. Note the gray-purple macules centrally, signifying resolving lesions of lichen planus. (Reproduced with permission from Burgin S: Guidebook to Dermatologic Diagnosis. New York, NY: McGraw Hill; 2021, Figure 4-11A.)

The torso and arms of a patient with lichen planus shows dark, flat annular violaceous plaques.
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FIGURE 8-2.

Red-maroon polymorphic papules scattered diffusely on the trunk. Note the overlying scale on the papules located on the lower lateral trunk. (Reproduced with permission from Wolff K, Johnson RA, Saavedra AP, Roh EK. Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology, 8th ed. New York, NY: McGraw Hill; 2017, Figure 14-17.)

A patient with maroon and brown papules scattered across the trunk. The papules on the lower part of the trunk have grey scales.
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FIGURE 8-3.

Pink, flat-topped, clustered papules lacking overlying scale on the ventral wrist. Not the pink-red macules inferior and lateral to the papules, signifying postinflammatory erythema from resolving lichen planus. (Reproduced with permission from Soutor C, Hordinsky MK. Clinical Dermatology. New York, NY: McGraw Hill; 2013, Figure 9-10.)

A patient with smooth, Flat topped, light pink papules clustered on the ventral wrist. Smaller dark pink Macules are scattered laterally to the papules.
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FIGURE 8-4.

Red-purple polygonal flat-topped papules coalescing into plaques, one of which is linear, representing koebnerization. (Reproduced with permission from Soutor C, Hordinsky MK. Clinical Dermatology. New York, NY: McGraw Hill; 2013, Figure 9-11.)

A patient with rough, Flat topped, red papules on the anterior wrist. Some coalesce into a rough circular structure, others coalesce in a linear pattern on the forearm.
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FIGURE 8-5.

Discrete, pink-brown, polymorphic scaly papules on the forearm. (From Usatine RP, Smith MA, Mayeaux EJ Jr, Chumley HS. The Color Atlas and Synopsis of Family Medicine, 3rd ed. New York, NY: McGraw Hill; 2019, Figure 174-9. Reproduced with permission from Richard P. Usatine, MD.)

A photo shows several reddish nodular lesions with dry surface on the arm.
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FIGURE 8-6.

Brown-pink papules on the anterior shin adjacent to a gray patch of postinflammatory hyperpigmentation from resolving lichen planus. Note the variation in color, with several red-pink papules laterally and inferiorly on the shin. (Reproduced with permission from Burgin S: Guidebook to Dermatologic Diagnosis. New York, NY: McGraw Hill; 2021, Figure 3-28.)

A photo of a patient's leg with a few brown bumps of active infection with patches of postinflammatory hyperpigmented following lichen planus in between.
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FIGURE 8-7.

Numerous pink-purple papules, some with ...

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