What it is

➝ Lichen planus (LP) is a chronic, inflammatory skin and mucosal disease involving the immune-mediated attack on keratinocytes.

➝ It presents with purple, polygonal, pruritic, planar papules and plaques on the skin, as well as oral, genital, scalp (lichen planopilaris), and nail involvement.

➝ While many cutaneous cases resolve within 1–2 years, mucosal, nail, and hair follicle disease can be severe, chronic, and scarring, requiring systemic therapy.

➝ In Korea, systemic treatment is reserved for extensive, resistant, or disabling lichen planus, combining immunosuppressive and immunomodulatory approaches.

Why it’s done

→ To control severe itching, burning, or pain that disrupts daily life.

→ To prevent scarring alopecia in lichen planopilaris or permanent nail loss.

→ To reduce oral/genital discomfort that interferes with eating, intimacy, and quality of life.

→ To limit the psychosocial burden, since visible skin lesions often cause anxiety and stigma.

→ In Korea, systemic therapy is used when topical corticosteroids, calcineurin inhibitors, or phototherapy are insufficient.

Alternatives

→ Topical corticosteroids: First-line for limited cutaneous and mucosal LP.

→ Intralesional corticosteroids: For hypertrophic plaques or nail matrix disease.

→ Phototherapy (NB-UVB or PUVA): Useful for widespread cutaneous LP.

→ Systemic therapy: Required for severe, refractory, or scarring forms.

Preparation

→ Confirm diagnosis with clinical examination and skin/mucosal biopsy.

→ Baseline blood tests: complete blood count, liver and kidney function, hepatitis screening (since LP is sometimes associated with hepatitis C).

→ Review comorbidities and risk factors before choosing systemic therapy.

→ In Korea, dermatology clinics often perform baseline digital photography to track treatment response.

How it’s Done – Systemic Therapy Options

→ Oral corticosteroids

• Prednisone 0.5–1 mg/kg/day tapered over weeks.
• Used for acute, severe flares but not suitable long-term due to side effects.

→ Immunosuppressive agents

• Azathioprine: Effective for mucosal LP.
• Mycophenolate mofetil: Useful in refractory cases.
• Methotrexate: Sometimes used in lichen planopilaris and nail LP.
• Cyclosporine: Rapid relief in resistant LP but requires monitoring.

→ Retinoids

• Acitretin: Beneficial for hypertrophic LP and widespread disease.

→ Biologic therapy (emerging)

• Case reports support dupilumab and JAK inhibitors in resistant LP, though not yet standard.

→ Adjunctive measures

• Antihistamines for itching.
• Pain control for oral/genital erosive lesions.
• Gentle skincare and barrier protection.

→ In Korean practice, systemic corticosteroids are often used for short induction, followed by steroid-sparing agents such as azathioprine or cyclosporine.

Recovery

→ With systemic therapy, skin lesions often flatten within 4–8 weeks, though pigmentation may linger.

→ Oral and genital LP may take several months to improve.

→ Hair and nail disease require early aggressive treatment to prevent irreversible damage.

→ Long-term remission is possible, but relapse is common, requiring maintenance or retreatment.

Complications

→ Uncontrolled LP: Scarring alopecia, nail dystrophy, strictures in mucosal disease.

→ Medication-related:

• Corticosteroids: weight gain, osteoporosis, diabetes, hypertension.
• Azathioprine: bone marrow suppression, hepatotoxicity.
• Cyclosporine: nephrotoxicity, hypertension, gum hyperplasia.
• Acitretin: dryness, teratogenicity.

→ Psychological impact: Disfigurement and chronic pain can lead to anxiety and depression.

Treatment Options in Korea

→ Korean dermatology clinics follow an escalation model:

• Start with high-potency topical steroids and/or phototherapy.
• Add systemic corticosteroids for severe acute disease.
• Switch to steroid-sparing immunosuppressants (azathioprine, cyclosporine, methotrexate) for long-term control.

→ Oral and genital LP are often co-managed with oral medicine, gynecology, or urology specialists for comprehensive care.

→ Acitretin is available and used in resistant hypertrophic or widespread LP.

→ Some advanced centers are exploring dupilumab and JAK inhibitors for refractory LP under clinical programs.

→ Patient education in Korea emphasizes avoiding skin trauma (Koebner phenomenon), maintaining oral hygiene, and consistent follow-up.

→ With Korea’s multidisciplinary care, systemic therapy for LP is delivered in a personalized, closely monitored approach, improving outcomes and minimizing complications.