Lichen planus is a relatively common inflammatory condition that can affect the skin, mucous membranes, nails, and scalp. It's characterized by purplish, itchy, flat bumps on the skin and lacy white patches in the mouth or on the genitals, sometimes accompanied by painful sores. While the exact cause remains under investigation, it's believed to involve an immune response where the body's immune system mistakenly attacks its own cells.
Understanding Lichen Planus
Lichen planus can manifest with a variety of symptoms affecting different parts of the body. The rash associated with lichen planus is often described using the "six Ps": pruritic (itchy), polygonal (having many sharp angles), planar (flat-topped), purple papules (small bumps), and plaques (raised, discolored patches). This condition is classified as a lichenoid dermatosis because it causes firm, raised, discolored bumps on the skin. As inflammation develops, a purple, itchy rash with flat bumps can appear over several weeks due to the body’s immune system reacting to cells in the skin and mucous membrane.
While lichen planus can affect anyone, it's most prevalent in middle-aged adults between 30 and 60 years old. Oral lesions are more common in women than men. Overall, it affects around 0.22% to 1% of the adult population, with oral lichen planus impacting 1% to 4% of people worldwide.
Signs and Symptoms
Lichen planus can affect the skin, mucous membranes, and nails, each with distinct symptoms:
Skin:
- Red, purple, or bluish-shiny, flat bumps
- Tiny papules, ranging from the size of a pin tip (0.4 millimeters) to the width of a pencil (1 centimeter)
- Rash development along scratch lines when the skin is scratched
- Itchiness
- Hair loss (rare)
- Darkening of the skin after lesions heal
Mucous Membranes:
- Lacy white patches on the tongue or inside the cheeks
- Painful sores in the mouth, making eating difficult
- Painful sores on the genitals
- Scarring
Nails (affecting about 10% of those with lichen planus):
- Nail scarring
- Nail cracking, splitting, and/or loss
- Dark lines from the tip to the base of the nail
Possible Causes
The precise causes of lichen planus are still being researched, but the condition appears to involve an immune response that leads to inflammation and the resulting rash and other symptoms. In individuals with lichen planus, T cells, which normally protect the body from infection, may react to a protein in the skin and mucous membranes.
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Several factors may trigger this immune response, including:
- Allergic reaction to metal in dental fillings
- Infection with the hepatitis C virus
- Taking pain relievers like nonsteroidal anti-inflammatory drugs (NSAIDs)
- Physical and emotional stress
- Vaccines
- Candida infection
- Changes in the oral microbiome
- Vitamin D deficiency
In rare cases, a type of lichen planus known as familial bullous lichen planus can run in families. Systemic viral infections, such as hepatitis C, seem to modify antigens on the surface of skin cells (keratinocytes) that may trigger the immune response. Studies also suggest that oral lichen planus may be associated with vitamin D deficiency. Patients with oral lichen planus had more abundant populations of Campylobacter rectus, Fusobacterium nucleatum, and Neisseria mucosa in their oral microbiomes.
Diagnosis
A GP can usually diagnose lichen planus by examining the rash and asking about your symptoms. The presence of typical purple, flat-topped bumps and white lacy patterns aids in clinical diagnosis. A skin biopsy involves removing a small sample of affected tissue for microscopic examination. This helps confirm the diagnosis by revealing the distinctive inflammatory patterns and ruling out other diseases like psoriasis or eczema.
Functional Medicine Approach
A functional and integrative medicine approach to lichen planus focuses on uncovering contributing factors and addressing them through diet, lifestyle, and supplementation. This approach complements conventional treatments to support overall well-being and quality of life.
Functional Medicine Labs
Functional medicine testing can help identify factors that may contribute to lichen planus:
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- Hepatitis C Virus Testing: Since lichen planus is sometimes associated with hepatitis C infection, testing for the virus is recommended. Antibodies to the hepatitis C virus can be measured in the blood to identify infection.
- Vitamin D Levels: Vitamin D deficiency is associated with oral lichen planus and immune system dysregulation. Measuring vitamin D levels can determine if supplementation is needed.
- Folate Levels: Research suggests that patients with lichen planus may have decreased folate levels. Folate levels can be evaluated to determine if supplementation may be needed to support healthy levels.
- Candida Testing: Increased levels of oral Candida have been associated with oral lichen planus. Blood and urine testing can provide a comprehensive picture of candida overgrowth in the body. For example, the Candida Profile measures IgA, IgG, and IgM reactivity to Candida to help determine if this fungus is causing an immune reaction. Urine testing can be done at home to detect Candida DNA that can signal invasive fungal presence.
- Skin Biopsy: A skin biopsy may be used to take a small piece of affected tissue and examine it under the microscope to see if the cells show typical changes involved in lichen planus.
Conventional Treatment
Depending on the level of discomfort, location, and extent of lichen planus, various options may be considered. Uncomplicated lichen planus on the skin often clears up on its own in a few months to years. If the skin rash is causing discomfort or fails to resolve, a topical corticosteroid cream or ointment may be used to help ease discomfort and support skin health.
In more severe or widespread cases, corticosteroids may be given orally or by injection. In other cases, the oral antimalarial medication hydroxychloroquine (Plaquenil), retinoids, and oral antibiotics like metronidazole (Flagyl) may be used. Antihistamines are sometimes also added to address the itching associated with lichen planus. When lichen planus is more severe, medications are used to alter the immune response, such as cyclosporine (Sandimmune), azathioprine (Azasan), methotrexate (Trexall), mycophenolate (Cellcept), sulfasalazine or thalidomide (Thalomid).
In other cases, phototherapy can help manage lichen planus. This treatment involves exposing the affected skin to ultraviolet B light two to three times a week for several weeks.
Medical treatment of oral lichen planus (OLP)
Medical treatment of oral lichen planus (OLP) is essential for the management of painful, erythematous, erosive, or bullous lesions. The main concerns with available therapies are the local and systemic adverse effects and the possibility of lesion recurrence after treatment is withdrawn. Local exacerbating factors should be eliminated. Any sharp teeth or broken restorations or prostheses that are likely to cause physical trauma to areas of erythema or erosion should be treated with conventional dental measures. The teeth should be scaled to remove calculus deposits and reduce sharp edges. If the patient has an isolated plaquelike or erosive OLP lesion on the buccal or labial mucosa adjacent to a dental restoration, and if an allergy is detected by means of skin patch testing, the lesion may heal if the offending material is removed or replaced. Topical corticosteroids are the mainstay of medical treatment, though in rare cases, corticosteroids may be administered intralesionally for a focal lesion or systemically for diffuse recalcitrant lesions. [2] Some topical corticosteroid therapies may predispose the patient to oral pseudomembranous candidosis; however, this condition is rarely if ever symptomatic, and it generally does not complicate healing of erosions related to OLP. Erosive OLP that is unresponsive to topical corticosteroids may respond to topical tacrolimus. [2, 45, 46, 47] Other potential therapies for recalcitrant OLP include cyclosporine, [48] hydroxychloroquine, [49] azathioprine, [50] dexamethasone elixir, mycophenolate mofetil, [51] dapsone, [47] systemic corticosteroids, [2] and topical and systemic retinoids. Close monitoring of patients is essential when these medications are prescribed. Platelet-rich plasma (PRP) and platelet-rich fibrin (PRF) have been suggested as possible alternatives to corticosteroids in the treatment of OLP. In a systematic review and meta-analysis comparing PRP and PRF with intralesionally administered corticosteroids, the three agents were found to be comparably effective. Some evidence suggests that topical curcumin may help palliate pain and promote clinical healing in patients with OLP. If systemic drug therapy (eg, treatment with nonsteroidal anti-inflammatory drugs [NSAIDs], antimalarials, or beta blockers) is suspected as the cause of oral lichenoid lesions, switching to another drug may be worthwhile. This change must be undertaken only by the patient's attending physician. All OLP patients should be informed of the slightly increased risk of oral squamous cell carcinoma (SCC), the most common of all oral malignancies. [54] They should be advised that this risk may be reduced by eliminating tobacco and alcohol consumption and by consuming a diet rich in fresh fruits and vegetables, among other measures. Erosive and atrophic lesions can be converted into reticular lesions by using topical steroids. Therefore, elimination of mucosal erythema and ulceration, with residual asymptomatic reticular or papular lesions, may be considered an endpoint of OLP therapy. A 2020 article outlined a potentially useful treatment algorithm for OLP, along with a staging system that may help facilitate management decisions. Physical interventions that may be considered in the treatment of OLP include photodynamic therapy, phototherapy, cryotherapy, and laser therapy. A 2025 study found that photobiomodulation (PBM; also referred to as low-level laser therapy [LLLT]) using an 810-nm diode was effective for treating OLP, though more so for erosive OLP than for keratotic OLP. When OLP lesions are symptomatic, patients may avoid certain foods that may aggravate the symptoms. Although OLP does not increase the risk of dental caries or gingival disease, painful lesions (particularly those on the gums) can limit the patient's ability to maintain good oral hygiene. Typically, an oral medicine specialist or oral pathologist makes the primary diagnosis of OLP. Patients with OLP should be reexamined during active treatment, and lesions should be monitored for reduction in mucosal erythema and ulceration and alleviation of symptoms. Active treatment should be continued (with alternative therapies tried as appropriate) until erythema, ulceration, and symptoms are controlled. Patients should be followed at least every 6-12 months and possibly more frequently (eg, every 2-6 months) in cases of atrophic or erosive OLP. Patients with OLP should be instructed to pay attention to any exacerbations of symptoms or changes in the features of the lesions. In view of the potential association of OLP with oral SCC, an appropriate specialist should follow patients every 6-12 months. Candidal cultures or smears may be obtained periodically. Infections can be controlled with topical antimycotic preparations.
Nutrition Considerations
Nutrition plays a key role in the dysregulation of the immune system that occurs in inflammatory skin conditions like lichen planus. An anti-inflammatory diet can help support the body's natural defenses against inflammation that contributes to the skin lesions of lichen planus. One way of eating to support a balanced immune response is the Mediterranean Diet, which emphasizes whole fresh vegetables and fruits while limiting processed foods and additives, caffeine, and alcohol to support overall health.
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In particular, vitamin A-rich foods like carrots, sweet potatoes, kale, and winter squashes support the immune system and may help maintain skin and mucous membranes. Conventional treatment approaches to lichen planus may include the use of retinoid-based drugs that are derived from vitamin A to help relieve many of the symptoms. If a person is found to be deficient in folate with laboratory testing, folate-rich foods can be increased in the diet. These include beef liver, asparagus, beets, avocados, and legumes like garbanzo beans, pinto beans, and lentils.
If Candida overgrowth has been detected in patients with oral lichen planus, it can be helpful to focus on low-sugar fruits, non-starchy vegetables, non-glutinous grains, some fermented foods, and dairy products. To avoid further irritation and discomfort with oral lichen planus, it can help to avoid spicy or acidic foods or drinks such as hot peppers, citrus fruits, tomatoes, and alcohol. Crispy foods can aggravate lichen planus, particularly if there are open sores. Avoid eating toast, crusty bread, chips, crispy cookies, and similar crunchy foods. Caffeinated beverages also seem to aggravate lichen planus. Spicy, acidic, and citrus foods and beverages can aggravate lichen planus. You may need to avoid eating foods made with chili peppers, curry, large amounts of ginger or garlic, or other spicy dishes. Tomato and tomato products may cause problems.
Foods to Embrace for Lichen Planus
- Anti-Inflammatory Foods:
- Fruits and Vegetables: Rich in antioxidants and phytonutrients, fruits like berries and vegetables like leafy greens (spinach, kale) can help reduce oxidative stress and inflammation.
- Omega-3 Fatty Acids: Found in flaxseeds, chia seeds, and walnuts, as well as fatty fish like salmon and mackerel, omega-3s have potent anti-inflammatory effects.
- Herbs and Spices: Turmeric and ginger, widely used in both Ayurvedic and modern medicine, are known for their anti-inflammatory and immune-modulating properties.
- Probiotic-Rich Foods: Gut health is intimately linked to immune function, and an imbalance in gut bacteria can exacerbate autoimmune conditions.
- Hydrating Foods: Staying hydrated is crucial for maintaining skin health and flushing out toxins.
Foods to Avoid for Lichen Planus
- Pro-Inflammatory Foods:
- Refined Sugars and Processed Foods: These foods can spike blood sugar levels and increase inflammation.
- Fried and Oily Foods: In both conventional nutrition and Ayurveda, fried and greasy foods are known to aggravate inflammation.
- Red Meat: High in saturated fats, red meat can contribute to systemic inflammation.
- Acidic and Spicy Foods: Tomatoes, Citrus, and Vinegar: These acidic foods can exacerbate lesions, particularly in cases of oral Lichen Planus. Spicy Foods: Hot peppers, curries, and chili powders can irritate the digestive system and lead to inflammation flare-ups.
- Dairy: Dairy can be inflammatory for some individuals, particularly those who are lactose intolerant or sensitive to casein.
Supplements & Herbs
Herbal and other supplements may help support the immune system and soothe skin in lichen planus. Supplementation can help replenish deficiencies of vitamin D. While topical treatment with aloe vera gel or turmeric may help support skin health.
- Vitamin D: Vitamin D plays a crucial role in supporting the immune system, including impacting the function of T cells. If insufficient levels are found on testing, vitamin D supplementation may help to replenish levels and support the immune response. Studies show significant improvement in symptoms of lichen planus with vitamin D supplementation as an adjuvant to conventional steroid therapy and/or placebo.
- Aloe vera: Some studies suggest that aloe vera gel may help support the management of lichen planus of the vulva and mouth. For example, a randomized, double-blind clinical trial of 40 patients with oral lichen planus showed that aloe vera gel was more effective than a topical synthetic corticosteroid (triamcinolone acetonide) for reducing symptoms over eight weeks of treatment. Similarly, aloe vera mouthwash seems to help support oral health when lichen planus impacts the mouth.
- Turmeric: Curcumin, which is derived from turmeric, has antioxidant, anti-inflammatory, antimutagenic, antimicrobial, and anticancer properties. Turmeric ointment seems to support the management of inflammation and modulate the immune system to improve the appearance and comfort of oral lichen planus.
Integrative Approaches
In addition to diet and supplementation, integrative approaches may help support the management of symptoms of lichen planus.
- Oatmeal: Oatmeal can be soothing to the skin lesions that occur in lichen planus. You can apply oatmeal to the skin by grinding oatmeal into a powder and adding it to a bath to soak your skin or making a sticky paste with ground oats and water that is applied to the skin for about ten minutes.
- Stress management: Lichen planus can flare up and get worse with stress, so finding a stress management practice that works for you can help manage symptoms. Mind-body practices like yoga, breath work, meditation, and tai chi activate the body's relaxation response to inhibit the body’s stress response and bring a greater sense of relaxation.
- Homeopathy: Homeopathy is a complementary healing modality that uses infinitesimal small quantities of substances to support health. Homeopathic therapies are individualized, taking into account many factors about an individual, such as personality, pathology, and lifestyle preferences. Therefore, remedies need to be matched to the individual by a qualified practitioner. A randomized controlled trial showed that the homeopathic medicine Ignatia amara 30c reduced lesion size and discomfort in patients with histopathologically-confirmed oral lichen planus over four months of treatment. Small case studies have also shown that homeopathic Aurum metallicum, Lycopodium, and Carcinosinum may support the management of lichen planus symptoms.
The Role of Vitamin D in OLP Treatment
Vitamin D has anti-inflammatory and immunomodulatory properties, along with its regulatory effect on keratinocyte proliferation and differentiation; thus, suggesting its possible role in the treatment of OLP.
A systematic review was conducted to evaluate the therapeutic role of vitamin D in OLP treatment. The results of the review showed that all the included studies demonstrated significant amelioration in the OLP symptoms in patients who were given vitamin D supplements as an adjuvant to the conventional steroid therapy and or placebo.This systematic review signifies the role of vitamin D as adjuvant therapy for OLP.
Ayurvedic Perspective
In Ayurveda, Lichen Planus is often associated with an imbalance in the Pitta dosha, which governs heat and metabolism. Diet is one of the main ways to pacify Pitta and bring the body back into balance.
- Balancing Pitta and Kapha Doshas: Cooling and hydrating foods, such as cucumbers and coconut water, help balance Pitta.
- Eliminating Ama (Toxins): Proper digestion is essential in Ayurveda to prevent the buildup of toxins.
- Individualized Nutrition: Ayurveda emphasizes that each person’s constitution (Prakriti) is unique.
Homeopathic Treatment
Homeopathy has proven its effectiveness in the treatment of lichen planus. Homeopathic medicine targets the altered immunity of the body and brings it back to normalcy over a period of time. Homeopathy treatment helps in the resolution of existing lesions, reduces itching, and controls the further spread of lesions. It gives lasting relief to patients.
Living with Lichen Planus
Lichen planus can be a chronic condition with periods of remission and flare-ups. Without proper management, it may cause lasting skin discoloration, scarring, or hair loss.
Management Tips
- Consistency: Managing lichen planus symptoms involves consistent care and attention.
- Medications: Regular use of prescribed medications.
- Avoid Irritants: Identifying and steering clear of factors that provoke or worsen lichen planus is crucial.
- Moisturize: Regular moisturizing can help control flare-ups.
- Regular Self-Examination: Regularly examining yourself and being aware of any changes that occur will help you to identify any problems at an early stage.
- Dental Health: You should also visit your dentist regularly to ensure that your teeth and gums remain healthy, and that any ulcers or patches that form in your mouth are examined and treated promptly.
- Monitor Ulcerated Areas: Pay close attention to ulcerated areas in your mouth or genitals that don’t heal and persist for a long time.
Recent Research and Emerging Therapies
Recent studies and ongoing research aim to deepen understanding of lichen planus, its causes, and potential new therapies. Researchers are investigating the role of genetic mutations and immune system dysregulation in the development of lichen planus. Emerging therapies such as biologics and novel immunomodulators hold promise for more effective and personalized management of lichen planus.