Erosive Lichen Planus: Symptoms, Diagnosis, Treatment Guide
Chronic painful mucosal condition affecting mouth, genitals; learn symptoms, diagnosis, treatments.
What is erosive lichen planus?
Erosive lichen planus is a rare, chronic inflammatory condition characterized by painful erosions and ulcers primarily affecting mucosal surfaces, especially the mouth (oral lichen planus) and genitals (vulvovaginal or penile lichen planus). This severe variant leads to persistent ulcers that heal with scarring, predominantly impacting adults, particularly women, and is uncommon in children. In women, it may manifest as vulvovaginal-gingival syndrome, involving ulceration of the mouth, gums, vulva, and vagina, while the male equivalent is peno-gingival syndrome.
The condition arises from an abnormal immune response targeting basal keratinocytes in the mucosa and skin, resulting in liquefactive degeneration and subepithelial clefting. Unlike classic lichen planus with its violaceous papules and Wickham striae, erosive forms show predominant ulceration due to extensive epidermal loss. It often coexists with other lichen planus subtypes, complicating diagnosis and management.
Who gets erosive lichen planus?
Erosive lichen planus primarily affects middle-aged to older adults, with a strong female predominance, especially in postmenopausal women. Approximately 25% of patients with oral lichen planus have concomitant vulvovaginal involvement. Risk factors include autoimmune disorders, hepatitis C infection, certain medications (e.g., NSAIDs, beta-blockers), and dental materials like amalgam fillings. Genetic predisposition and triggers like stress or trauma (Koebner phenomenon) may contribute.
- Prevalence: Rare overall; mucosal erosive form in 10-20% of lichen planus cases.
- Demographics: Women > men; peak incidence 40-60 years.
- Associations: Autoimmune diseases (thyroiditis, vitiligo), HCV (up to 30% in some populations).
What causes erosive lichen planus?
The exact etiology remains unknown, but it involves a T-cell mediated autoimmune attack on epithelial basal cells, triggered by genetic susceptibility (HLA-DR1, HLA-DQB1*0201) and environmental factors. Antigen-specific cytotoxic CD8+ T cells infiltrate the dermal-epidermal junction, releasing cytokines like IFN-γ and TNF-α, leading to keratinocyte apoptosis.
Common triggers include:
- Viral infections (hepatitis C, HSV).
- Drugs (antimalarials, thiazides, penicillamine).
- Dental restorations (amalgam, metals).
- Trauma or friction in affected sites.
No infectious agent directly causes it, but secondary bacterial or candidal infections occur due to mucosal barrier disruption.
What are the symptoms of erosive lichen planus?
Symptoms are dominated by pain, burning, and functional impairment due to chronic ulceration.
Oral cavity
Erosions appear as irregular, persistent ulcers on buccal mucosa, tongue sides, gums, or lips, larger and longer-lasting than aphthae (weeks to months). Pain intensifies with eating spicy/hot/acidic foods, causing weight loss, nutritional deficits, and depression. Desquamative gingivitis presents as red, peeling gums with gingival bleeding. Other signs: white lacy reticular streaks (Wickham striae).
- Burning mouth syndrome-like pain.
- Sensitivity to temperature, chewing.
- Halitosis from secondary infection.
Genital involvement
In women, bright red raw erosions affect labia minora, introitus, causing stinging urination (dysuria), dyspareunia, vulvodynia, and severe itch. Scarring leads to labial adhesions, clitoral hood loss, vaginal stenosis. Desquamative vaginitis causes purulent discharge and contact bleeding.
In men, penile erosions cause painful ulcers on glans or shaft, with gingival involvement in peno-gingival syndrome.
Other sites
Esophagus (dysphagia), larynx (hoarseness), nails (dystrophy), scalp (scarring alopecia), eyes (conjunctivitis).
Clinical features and diagnosis
Diagnosis is primarily clinical, supported by histopathology. Key features:
- Oral: Erosive ulcers >1cm, desquamative gingivitis, reticular plaques.
- Vulval: Erythema, erosions at introitus, scarring.
- Vaginal: Fragile mucosa, discharge.
Histology: Hydropic degeneration of basal layer, Civatte bodies, band-like lymphocytic infiltrate, Max-Joseph spaces. Direct immunofluorescence shows fibrinogen and C3 at dermoepidermal junction.
Differential diagnosis:
| Condition | Distinguishing Features | Treatment |
|---|---|---|
| Pemphigus vulgaris | Flaccid blisters, acantholysis on biopsy, Nikolsky sign | Systemic steroids, immunosuppressants |
| Mucous membrane pemphigoid | Scarring, linear IgG/C3 on DIF, eyes often involved | Dapsone, immunosuppressants |
| Aphthous stomatitis | Small round ulcers, self-limiting (7-10 days) | Topical steroids |
| Candidiasis | White plaques scrape off, KOH positive | Antifungals |
| Erosive candidiasis | Response to antifungals, PAS-positive hyphae | Fluconazole |
Biopsy is essential to exclude malignancy (squamous cell carcinoma risk 1-2%).
Treatment of erosive lichen planus
Management is challenging, requiring multimodal, long-term therapy to control symptoms, promote healing, and prevent scarring. No cure exists; focus on immunosuppression and symptom relief.
First-line: Topical corticosteroids
High-potency agents (clobetasol 0.05% ointment/propionate) applied 2-3x daily for 4-6 weeks, then maintenance 1-3x/week. For oral: gels, mouthwashes (dexamethasone elixir), custom trays. Vulvovaginal: ointment in vagina nightly. Response rates up to 75%.
Second-line: Topical calcineurin inhibitors
Tacrolimus 0.1% ointment or pimecrolimus 1% cream, 1-2x daily. As effective as clobetasol for oral erosions; useful steroid-sparing. Monitor for local stinging, rare malignancy risk.
Systemic therapies (severe/refractory)
- Prednisone: 0.5-1mg/kg/day taper.
- Methotrexate: 10-20mg weekly + folic acid; monitor LFTs.
- Others: Hydroxychloroquine, mycophenolate, cyclosporine, acitretin, minocycline.
Retinoids for hypertrophic lesions.
Symptom relief
- Topical lidocaine for pain.
- Antihistamines (hydroxyzine) for itch.
- Emollients, avoid irritants (spicy foods, tight clothing).
Surgical interventions
Vaginal dilators, adhesiolysis for scarring.
Monitor for secondary infections (Candida, HSV); treat promptly.
Complications
Chronic pain impairs quality of life, nutrition, sexuality. Scarring causes vaginal/urethral stenosis, dyspareunia. Increased squamous cell carcinoma risk in persistent ulcers (1-5%). Nutritional deficiencies, depression from oral pain.
Prevention and prognosis
Avoid triggers (medications, trauma). Regular dental/gynecologic follow-up for early intervention. Prognosis: Chronic relapsing; 50-70% achieve remission with therapy, but flares common. Malignant transformation rare but mandates surveillance.
Frequently Asked Questions
Q: Is erosive lichen planus contagious?
A: No, it is an autoimmune condition, not infectious.
Q: Can erosive lichen planus be cured?
A: No cure, but symptoms can be well-controlled with treatment.
Q: Does it increase cancer risk?
A: Yes, slight risk of squamous cell carcinoma in chronic ulcers; regular biopsies recommended.
Q: What is the best treatment for vulvovaginal erosive lichen planus?
A: High-potency topical steroids (clobetasol) or tacrolimus; systemic agents if refractory.
Q: How is desquamative gingivitis managed?
A: Topical corticosteroids in trays or rinses; rule out pemphigoid.
References
- Diagnosis and Treatment of Lichen Planus — American Academy of Family Physicians. 2011-07-01. https://www.aafp.org/pubs/afp/issues/2011/0701/p53.html
- Erosive lichen planus — DermNet NZ. Recent access 2026. https://dermnetnz.org/topics/erosive-lichen-planus
- Oral lichen planus – Diagnosis and treatment — Mayo Clinic. Recent update. https://www.mayoclinic.org/diseases-conditions/oral-lichen-planus/diagnosis-treatment/drc-20350874
- Lichen Planus Erosive Form — MD Searchlight. Recent. https://mdsearchlight.com/skin-problems-and-treatments/lichen-planus-erosive-form/
- Lichen Planus Erosive Form — StatPearls, NCBI Bookshelf. 2023. https://www.ncbi.nlm.nih.gov/books/NBK560700/
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