Lichen Planus and its Homoeopathic Management

Dr Modesty Tyngkan

Abstract: Lichen Planus is an immune mediated inflammatory disorder that affects the skin and mucous membranes. The cause is unknown, it may be due to genetic susceptibility or in association with disease of altered or disturbed immunity. This article focuses on the clinical presentation of different variants of Lichen Planus and some homoeopathic therapeutics.

Introduction:
Lichen planus (LP) is a papulosquamous idiopathic chronic inflammatory disorder that affects the skin, hair, scalp, nails, and mucous membranes. The primary cutaneous lesions are Pruritic, Polygonal, Flat-topped, Violaceous papules. There are different variants of LP with diverse clinical presentation. The different clinical subtypes are based on morphology of the lesions and the site of involvement. The term ‘lichenoid’ is used by clinician to describe a flat topped shiny papular eruption resembling LP.

Pathogenesis:
Etiopathogenesis of LP is mostly unknown however it is considered to be an immunological mediated disorder. Studies showed that LP may have different pathogenesis. There may be genetic susceptibility to LP. An epidemiological association of LP with hepatitis C virus infection has been recorded in various studies. Another putative antigen in Oral LP is associated with mercury in dental amalgam. Anxiety and depression may be risk factor for development of LP.

Associated condition
Idiopathic LP has been reported in association with disease of altered/disturbed immunity including

• Ulcerative colitis
• Alopecia areata
• Vitiligo
• Pemphigus
• Dermatomyositis
• SLE
• Also, with Thymoma, Primary biliary cirrhosis, Diabetes mellitus, Myasthenia gravis

Clinical features:

• Distribution Site: –

1. Wrists (volar/flexor aspect of wrist)
2. Ankles
3. Oral Mucous membrane
4. Shins
5. Lower back and genitalia

Characteristic Skin lesion:

• Shiny, Violaceous flat-topped papules & plaques
• Purplish papules, purplish nodules on skin at sites of friction
• Sore/painful/asymptomatic
• Polygonal
• Severe pruritus
• Lacy white marking
• Purplish nodules on skin at sites of friction
• Close examination of the surface of these papules often reveals a lacy network of fine white lines (Wickham’s striae)

Oral mucosa LP:

• Common sites are buccal mucosa, tongue, gingiva, lips.
• White striae in mouth present on a spectrum ranging from a mild, white, reticulate eruption of the mucosa to a severe, erosive stomatitis.
• Ulcers to severe erosive stomatitis, erosive gingivitis
• White streaks, often forming a lacework, on the buccal mucosa are highly characteristic
• Erosive stomatitis may persist for years and may be linked to an increased risk of oral squamous cell carcinoma.
• Occasionally LP lesion from oral mucosa extend to larynx/esophagus- results in dysphagia & formation of benign strictures
• In young men LP are restricted to genitalia and/ or mouth
• In female erosive LP of the genitalia with desquamative gingivitis

VARIANTS:

1. Hypertrophic LP
2. Annular LP
3. Atrophic LP
4. Ulcerative (erosive) LP
5. Lichen Planus actinicus
6. Lichen Planopilaris (LPP)

Hypertrophic LP

• Hypertrophic lichen planus of the lower leg may occasionally be mistaken for eczema (clustered papulovesicular) if there are no characteristic lesions elsewhere.
• Histology- In hypertrophic LP, the epidermis may show a pseudo-epitheliomatous appearance with extreme irregular acanthosis

Annular LP: Depressed, slightly atrophic center, much less often the margin is wide and the central area is quite small.

Atrophic LP: Lesion tend to be few in no usually occur after resolution of typical LP. The atrophy may be the result of faded annular lesions or resolved hypertrophic lesions on the lower legs especially.

Ulcerative (erosive) LP:

• Epidermal ulceration with LP at margins

Lichen Planus actinicus:

• It is a photo disributed variant of LP
• Occur in children & young adults with dark skin lining in tropical countries
• Lesion occur in exposed skin (usually face as well defined anular/discoid patches
• Deeply hyperpigmented center surrounded by a striking hypopigmented zone
• Sunlight exposure appears to be central to pathogenesis of actinic LP

May also mimic melasma

Lichen Planopilaris (LPP)or Follicular LP:

• A variant in which groups of ‘spiny’ lesions resembling keratosis pilaris develop around hair follicles (lichen planopilaris) is not uncommon.
• Lichen planopilaris more often forms only a minor feature of the disease, but occasionally this type of lesion may predominate.
• Involvement of the scalp (lichen planopilaris) may lead to scarring alopecia,

Other Variants of LP:

• LP pigmentosus: The macular hyperpigmentation involves chiefly the face, neck and upper limbs. Varies from slate grey to brownish black; it is mostly diffuse, but reticular, blotchy. Commonly seen in India & middle east
• Linear LP: Linear lesions as a Koebner effect are frequently found in LP. Isolated linear lesions, usually made up of small papules in close apposition.
• Multiple linear LP lesions following the lines of Blaschko have been reported & was documented in HIV patient.
• Zosteriform LP has also been described

Variants based on site of involvement:

1. Nails LP
2. Palmoplantar LP
3. Mucosal LP
4. Esophageal LP
5. Genital LP

Other Cutaneous eruptions clinically resembling LP have been observed after administration of numerous drugs including; Thiazide diuretics, Gold, antimalarial agents, penicillamine, phenothiazines and in patients with skin lesions of chronic graft-versus-host disease. In addition, LP may be associated with hepatitis C infection

Complications:

• Nails – Finger nails are commonly affected

Exaggeration of longtitudinal lines & linear depressions d/t slight thinning of nail plate

Elevated ridges

Adhesion between dorsal manifold & nailbed may cause partial destruction of nail

Nail involvement may lead to permanent deformity or loss of fingernails and toenails.

• Hair – Alopecia patches, atrophic cicatricial alopecia
• Mucous membrane – squamous cell carcinoma

Diagnosis

1. Clinical Evaluation
2. Biopsy for histopathology

Differential diagnosis:

The less typical LP may be mistaken for

1. Plane warts
2. Eczematous eruption with lichenification from scratching
3. Pityriasis Rosea: Acute self-limiting-herald patch, bright red colour progress to black-usually in trunk
4. Lichen Simplex Chronicus: lichenified skin due to chronic rubbing/scratch
5. Lichen planus pemphigoides: occur in the setting of lichen planus in both adults and children, tense subepidermal blisters arise from the lesions of lichen planus and normal skin.

Homoeopathic Management

Homoeopathy treatment focus on the root cause, the triggering factors the pathological changes and the person as a whole. This is done by detailed medical history of the patient. The physical signs and symptoms appear because of disturbed vital functions either from external impressions having a depressing effect and the consequent reaction of the vital force or from some hidden miasm coming into its full expression.

Indications of some homoeopathic medicines:

Antimonium crudum:

• Scaly, pustular eruption with burning and itching, worse at night. It is pre-eminently a scrofulous medicine, corresponding to gross constitutions with tendency to rough scaling skin with horny patches. With these horny patches is great tenderness.
• A notable characteristic is the thickly coated tongue. Generally, it is thick and white; milky-white; or like whitewash evenly laid. The edges may be red and sore
• Sensitive to cold bathing.
• Thick, hard, honey-coloured scabs.
• Itching when warm in bed.
• Dry skin
• Itching of scalp and falling out of hair
• Nails discoloured and deformed

Sulphur:

• Dirty, filthy people, prone to skin affections. Aversion to being washed.
• Very red lips and face
• Dry, scaly, unhealthy; every little injury suppurates. Itching, burning; worse scratching and washing.
• Skin affections after local medication. Pruritus, especially from warmth, is evening, often recurs in spring-time, in damp weather.

Arsenicum album

• Itching, burning, swellings; œdema, eruption, papular, dry, rough, scaly; worse cold and scratching.
• Ulcers with raised and hard edges, surrounded by a red and shining crown; with the bottoms like lard, or of a blackish-blue colour, with burning pains or shooting, principally when the parts affected become cold.
• A very deep acting remedy, affecting every organ and tissue

Arsenic Iodatum:

• Dry, scaly, itching.
• Marked exfoliation of skin in large scales, leaving a raw exuding surface beneath.

Kali bichromicum:

• Papular eruption
• Hands become covered with deep, stinging cicatrice
• Ulcer with punched-out edges, with tendency to penetrate and tenacious exudation

Agaricus muscarius:

• Eruption of small pimples like with red areola and violent itching
• Sensation in various parts as if ice cold needles were piercing the skin

Dulcamara:

• Pruritus, always worse in cold, wet weather Humid eruptions on face, genitals, hands Warts, large, smooth, on face and palmar surface of hands.
• Thick, brown-yellow crusts, bleeding when scratched.

Juglans cineraria:

• Eruption resembling eczema simplex on upper chest, with itching pricking when heated by over-exertion
• Pustules on thighs, hips, and nates, with itching and burning, a few pustules on body, face, and arms
• Itching in spots, now here, now there, on head, neck, and shoulders, with pricking, burning and redness
• Itching on arms > scratching.

Ledum palustre:

• Eruption of small pimple like red millet seed over the body
• Excessive itching on the back of both feet worse after scratching and by warmth of bed > scratching.

Sulphur iodatum:

• Obstinate skin affections; painless enlargement of glands, and infiltration of tissues with thickening and induration after inflammation are marked features.

REFERENCES

1. Burns T, Breathnach S,Cox N, Griffiths C. Rooks textbook of dermatology. 7^th ed. Volume 3. Blackwell Publishing Ltd
2. Fauci As, Kasper DL, Braunwald E, Hauser Sl, Jamesson JL, Loscalzo J, Harrison’s principles of internal medicine. 19^th ed. Volume 1. New York:MC Graw Hill
3. Roberts AH. Principle and Art of cure Homoeopathy. reprint edition
4. Douglass ME. Skin Disease Their Description, Etiology, Diagnosis and Treatment. Bjain publishers Ltd
5. Boericke William, New Manual of Homoeopathic Materia Medica with Repertory. Bjain publishers Ltd
6. Clarke J.H. A Dictionary of Practical Material Medica Bjain publishers Ltd

Dr Modesty Tyngkan
PG Scholar, Department of Practice of Medicine
Father Muller Homoeopathic Medical College & Hospital Mangalore
Under the Guidance of Dr M K Kamath
Professor HOD Department of Practice of Medicine
ttyngkan@gmail.com