Therapy

Because LP is generally a self-limiting disorder, the aim should be to provide the patient with as much comfort as is possible with minimal risk. It must be kept in mind that the pruritus of limited disease can be very distressing, and eruptive LP is socially humiliating. Whenever possible, try to limit treatment to topical or intralesional regimens. When disease is extensive, this is not always possible and there is a point where systemic therapy is needed.

Topical Therapy

Limited LP will respond to topical steroids but effective treatment usually requires the most potent topical that is safe in a given skin region (carefully review the section in Chapter 4 on topical steroids). Resistant areas will often respond to a combination of a steroid cream alternated with topical tretinoin cream in the highest concentration tolerated. The prescribing practitioner should pay careful attention to surface area and total amount of topical steroid in use. If either of these is excessive, systemic treatment should be considered rather than trying to accomplish the same effect with an uncontrolled topical treatment.

Hypertrophic LP may respond to topical corticoids, but is less steroid-sensitive than other inflammatory skin conditions and often requires a group I steroid in an optimized vehicle. An alternative is to use a weaker product with plastic wrap occlusion. This method, which was developed prior to the arrival of the superpotent steroids, has a higher incidence of side effects and often leads to patient compliance problems.

Oral LP often responds well to a regimen of topical 0.05% fluocinonide ointment administered three to four times during the day. This agent is poorly absorbed from the bowel and systemic absorption has not been a problem. At bedtime, topical tretinoin cream is applied starting with the highest strength tolerated. Consider starting with the 0.05% cream and switching to the 0.1% concentration as the membrane responds. Tacrolimus ointment 0.1% has also proved quite effective in the treatment of oral LP. This immune modulator avoids the cutaneous atrophy associated with topical steroids but is fairly new and unique side effects may not yet be fully appreciated. Keep in mind that persisting ulceration of oral LP may signal a rare conversion to squamous cell carcinoma and a timely referral to a dermatologic consultant may be life-saving.

Intralesional Therapy

Intralesional therapy is useful for resistant localized LP and hypertrophic LP. Consider starting at a concentration of 2.5 mg/cc of triamcinolone acetonide diluted in physiologic saline. Often 5- or even 10-mg/cc concentrations are needed with thick hypertrophic areas. More concentrated solutions limit the area that can be safely treated without risk of systemic effects. The total monthly dose should always be recorded and monitored. On occasion, this technique may be useful with resistant oral lesions.

Systemic Therapy

Generalized disease that is too extensive for safe or effective topical treatment, and nail or scalp involvement that can leave disfiguring scarring, are indications for systemic therapy. If the practitioner is unsure of the situation, prompt referral to a dermatologist is then indicated. Among the multitude of systemic agents which have been reported effective, the following drugs are worth consideration.

Griseofulvin: Several years ago, this antifungal agent was reported in a controlled study to clear a high proportion of cases. Although subsequent studies have been conflicting, it is an agent with a very reasonable side-effect profile and is well worth consideration in the treatment of widespread nonscarring LP or LP with a concomitant dermatophyte infection. In the latter situation, it is the initial drug of choice. When grise-ofulvin is effective, some improvement is seen within 30 days. This is usually evident as decreased pruritus, flattening of the papules, and a cessation of new lesions. Because of its slow onset and spotty efficacy, it should not be used for rapidly advancing exanthematic LP or where significant scarring can occur. With adults, consider starting with a dose of 1 g/day of ultramicronized griseofulvin divided into four equal doses. Administration at the start of a meal, or with milk enhances absorption and minimizes GI side effects. A baseline CBC should be obtained, as well as liver chemistries if there is any suggestion of prior liver disease. The drug is continued until clearing is complete. With prolonged use, a CBC and liver panel are recommended on a 3-month schedule. Much has been said about griseofulvin causing LP-like drug eruptions. This has been a rare event but should be kept in mind in the face of worsening disease.

Systemic steroids: In cases of rapidly advancing exanthematic LP, or when scarring scalp or nail lesions are present, systemic steroids are justified. In adult cases, prednisone in a single morning dose of 30 to 40 mg/day should be initiated then rapidly tapered once control is achieved. Often small areas of resistant disease persist that require topical treatment while the systemic agent is withdrawn. A practitioner using systemic corticoids must be fully aware of the side effects, contraindications, and monitoring required for safe usage.

Other agents: Systemic retinoid therapy, dapsone, and antimalarial agents have each been reported helpful in treating special problem types of LP. As these treatments are outside of standard therapy, such cases should be referred to a dermatological consultant.

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