Integrative and Complementary Approach to Lichen Planus

If you experience a red or purplish rash that itches and spreads to several areas of your skin and mucous membranes, you may have lichen planus. Lichen planus is a common inflammatory condition that causes purple, itchy, flat bumps on the skin and lacy white patches on the mouth and genital mucosa, sometimes with painful sores. 

While the cause of this condition is not fully understood, it seems to involve an immune response where an abnormal reaction by the immune system leads to an attack on skin or mucous membrane cells.

A functional and integrative medicine approach to lichen planus uncovers contributing factors and addresses them using diet, lifestyle, and supplementation. This can complement conventional treatment to reduce side effects and improve quality of life.

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What is Lichen Planus?

Lichen planus causes purplish-raised bumps on the skin and mucous membranes. It is most common on the skin around the wrists and elbows (flexor surfaces), the back of the hands (dorsal surfaces), and the fronts of the lower legs. About half of those who have skin lesions will also develop lichen planus in the mouth. These skin lesions are not contagious.

The rash of lichen planus is typically characterized by the six Ps: pruritic (itchy), polygonal (the rash shape has many sharp angles), planar (has a flat top), purple papules (bumps), and plaques (raised, discolored, patches). Since lichen planus causes firm, raised, discolored bumps on the skin, it is characterized as a lichenoid dermatosis. 

As inflammation develops in the skin due to the body’s immune system attacking cells in the skin and mucous membrane, a rash that appears purple, itchy, and flat bumps can develop over several weeks.

While this condition can impact anyone, it is most common in middle-aged adults between the ages of 30 and 60 years old, with oral lesions 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.

Lichen Planus Signs & Symptoms

Lichen planus can cause symptoms that impact the skin, nails, and mucous membranes. 

On the skin, lichen planus can present with:

• Red, purple, or bluish-shiny, flat bumps
• Papules that are tiny, usually about the size of the tip of a pin (0.4 millimeters) up to the width of a pencil (1 centimeter)
• When the skin is scratched, the rash may develop along the lines of scratching
• Itchiness
• Hair loss in rare cases
• Darkening of the skin after lesions heal

When lichen planus affects the mucous membranes, it can cause symptoms such as:

• Lacy white patches on the tongue or inside of the cheeks
• Painful sores in the mouth that can make it difficult to eat
• Painful sores on the genitals
• Scarring

Lichen planus can also impact the nails in around 10% of those affected, where it can cause symptoms like:

• Nail scarring
• Nail cracking, splitting, and/or loss
• Dark lines from the tip of the nail to the base of the nail

Lichen Planus Possible Causes 

The causes of lichen planus are still being researched, but the condition seems to involve an immune attack on cells in the skin and mucous membranes that causes inflammation and the resulting rash and other symptoms. In people with lichen planus, T cells of the immune system that normally help protect your body from infection attack a protein in the skin and mucous membranes.

The abnormal immune response that occurs in lichen planus may be triggered by factors like an allergic reaction to the metal in dental fillings, infection with the hepatitis C virus, taking pain relievers like nonsteroidal anti-inflammatory drugs (NSAIDs), physical and emotional stress, or vaccines. For example, systemic viral infections such as hepatitis C seem to modify antigens on the surface of skin cells (keratinocytes) that may trigger the immune response to attack them. 

Other research shows an association between Candida infection and oral lichen planus and changes in the oral microbiome in patients with lichen planus. Patients with oral lichen planus had more abundant populations of Campylobacter rectus, Fusobacterium nucleatum, and Neisseria mucosa in their oral microbiomes. 

Studies also suggest that oral lichen planus may be associated with vitamin D deficiency.

One rare type of lichen planus, known as familial bullous lichen planus, can run in families.

Functional Medicine Labs to Test for Root Cause of Lichen Planus

Functional medicine testing can help identify factors contributing to lichen planus so that they can be addressed as part of an integrated treatment approach. 

Hepatitis C Virus

Since lichen planus is sometimes associated with hepatitis C infection of the liver, testing for the virus can be done. Antibodies to the hepatitis C virus can be measured in the blood to help diagnose hepatitis C infection.

Vitamin D Levels

Since vitamin D deficiency is associated with oral lichen planus and dysregulation of the immune system overall, vitamin D levels can be measured in the blood to determine if supplementation may be needed to replete levels. 

Folate Levels

Folate (vitamin B9) plays important roles in DNA and amino acid metabolism. Research suggests that patients with lichen planus may have decreased levels of folate in their blood. Levels of folate can be evaluated by this test, offered by Access Med Labs.

Candida Testing

Since 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 from Alletess Medical Laboratory measures IgA, IgG, and IgM reactivity to Candida to help determine if this fungus is causing an immune reaction. Urine testing like the Candida Panel from RealTime Laboratories can be done at home to detect Candida DNA that can signal invasive fungal infections.      

Additional Lab Tests 

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 for Lichen Planus

Depending on the level of pain, location, and extent of lichen planus, various treatment options may be used. On the skin, uncomplicated lichen planus 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 pain, swelling, and inflammation. 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 treatment to address the itching caused by 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 clear lichen planus. This treatment involves exposing the affected skin to ultraviolet B light two to three times a week for several weeks.

Functional Medicine Treatment for Lichen Planus

Since these conventional approaches are not always effective and/or may cause undesirable side effects, a functional medicine approach can be integrated into care to help address the underlying contributing factors and improve quality of life. 

An anti-inflammatory diet, targeted supplementation, and integrative therapies such as mind-body practices and oatmeal baths can help soothe the skin and calm the immune system to improve lichen planus.

Nutrition Considerations for Lichen Planus

Nutrition plays a key role in the development of the dysregulation of the immune system that occurs in inflammatory skin conditions like lichen planus. A personalized anti-inflammatory diet can help reduce inflammation that contributes to the skin lesions of lichen planus. One way of eating to calm inflammation is the Mediterranean Diet which emphasizes whole fresh vegetables and fruits while limiting processed foods and additives, caffeine, and alcohol to balance inflammation. 

In particular, vitamin A-rich foods like carrots, sweet potatoes, kale, and winter squashes support the immune system and reduce inflammation, and can help to keep skin and mucous membranes healthy. 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 pain with oral lichen planus, it can help to avoid spicy or acidic foods or drinks such as hot peppers, citrus fruits, tomatoes, and alcohol.

Supplements & Herbs for Lichen Planus

Herbal and other supplements can help to regulate the immune system and soothe skin lesions in lichen planus. Supplementation can help replenish deficiencies of vitamin D. While topical treatment with aloe vera gel or turmeric helps to resolve lichen planus lesions.

Vitamin D

Vitamin D plays a crucial role in regulating 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 regulate 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 treat 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 heal lichen planus when it impacts the mouth.

Turmeric

Curcumin, which is derived from turmeric, has potent antioxidant, anti-inflammatory, antimutagenic, antimicrobial, and anticancer properties. Turmeric ointment seems to reduce inflammation and modulate the immune system to improve the appearance and discomfort of oral lichen planus. 

Complementary and Integrative Medicine for Lichen Planus

In addition to diet and supplementation, integrative approaches can help improve 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 treat disease. 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 pain 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 improve lichen planus symptoms.

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Summary

Lichen planus is a common chronic inflammatory disease that results from dysregulation of the immune system. This inflammation can cause red, purple, or bluish-shiny, flat bumps on the skin, lacy white patches on the tongue or inside of the cheeks, painful sores on the genitals, and/or nail changes.  

It can be triggered by various factors such as infection with hepatitis C, stress, exposure to certain metals or chemicals, a deficiency of vitamin D, and medications like NSAIDs.

A functional and integrative medicine approach to lichen planus uncovers contributing factors with testing to look at infections with hepatitis C or Candida and measure vitamin D and folate levels. Identified root causes are then addressed using diet, lifestyle, and supplementation. Topical treatments like aloe vera gel, turmeric, and oatmeal can soothe and heal skin lesions. Mind-body practices to manage stress, like yoga and meditation, are also helpful in healing the skin and improving quality of life.