Lichen planus is a non-contagious affection of the skin, characterized by the development of small, flattened papules, which frequently present a distinct central depression or umbilicus.
Lichen planus is an eruption of pimples, remarkable for their color, their figure, their structure, their habits of isolated and aggregated development, their habitat, their local and chronic character, and for the melasmic stains which they leave behind them when they disappear.
The color of the pimples is a dull crimson-red, more or less livid, and suffused with a purplish or lilac tinge.
In figure the papulae are flattened, smooth, and depressed on the summit, angular in outline, but slightly elevated, and of a size ranging between one and three lines in diameter; the flatness is rendered more conspicuous by the summit of the papule being occupied by a thin, horny, semi-transparent lamina of cuticle, depressed on the surface, and marked by the aperture of a follicle, which represents a sort of hilum. In structure, the papule of lichen planus is a hyperaemia with exudation, surrounding a follicle and surrounding a thin layer of horny, transparent cuticle; while the aperture of the follicle and its conical epidermic plug are visible in the center of the horny plate. The horny covering is in no wise a scale; it rises and falls with the papule and neither separates not exfoliates.
Lichen planus presents two principle forms of manifestation- discrete and aggregate.
The habitat of the eruption is also characteristic of the identity of lichen planus. It is pretty constantly met with on the front of the forearm, just above the wrist; in the hollow of the loins; on the lower half of the abdomen; on the hips; around the knees, particularly over the mass of the vastus internus muscle; on the forearms and calves of the legs, and in women around the waist and in the grooves occasioned by the garters. We have seen it also, but less frequently, on the palms of the hands and soles of the feet; and in two instances on the tongue, the buccal membrane, and the mucous lining of the fauces.
Lichen planus is essentially chronic and local in its habits. In distribution it is generally symmetrical, but occasionally is limited to one side of the body; sometimes occurring on one side in the upper extremity, and on the other in the lower. It has no constitutional symptoms of its own, and frequently prevails with very little disturbance of any kind.
Of course, the totality of the characters above noted are not to be found in every case. The characteristic feature, however, are the flattened umbilical papules. This central depression may not be noted in every papule; and when a number of them have run together and coalesced, it is commonly absent, and met with only on those in the neighborhood of, but which do not form a part of, the patch.
The duration of the affection is indefinite. It may undergo resolution, and the papules disappear after three or four months; or, especially when the eruption is extensive, may resist the best-directed treatment for a year or more.
Etiology.- No one has thus far offered a plausible explanation of the causes of lichen planus. It is undoubtedly a constitutional affection, but whether due to certain unknown changes in the blood, or to a reflected irritation from some special internal organ, is entirely unknown.
Diagnosis.- In general aspect the affection may be mistaken for a papular syphilide, or a papular eczema, but hardly for any other than those two diseases, except it be the lichen ruber of Hebra. The positive features, however, that have been detailed above do not occur in the diseases mentioned, and are sufficient of themselves to establish the diagnosis.
The prognosis of lichen planus is favorable, as there is little or no evidence that it tends either directly or indirectly to shorten life. The duration of a given eruption, however, is very uncertain, except that, in a general way, the more extensive the lesions the longer they may be expected to remain.
Treatment.- Locally, chrysarobin, thirty grains, with one ounce of traumaticin (liquor gutta percha). This should be painted on the spots daily until a considerable degree of local irritation is produced. Sedative applications should then be applied for a few days, and the skin allowed to recover from the effect of the drug. A single course of this sort will cause most of the spots to disappear.
When there is much itching, temporary relief is afforded by the application of cloths wrung out in hot water. Should the itching prove obstinate, a weak carbolized oil and lime water lotion, or grindelia robusta, dr. j. to water may be used.
The following ointment has proven very beneficial in many cases, to relieve the itching of lichen planus and eczema:
Rx Chloral hydratis, dr. ss.
Camph. pulv., dr. ss.
Acidi carbolici, m.x.
Balsum peru., dr.j.
Menthol, grs. xx.
Ung. zinci oxidi, q.s.ad. z3j.
M.fl. unguent., Sig. Apply morning and night.
As regards internal treatment the old school rely almost entirely upon arsenic, giving preference to Fowler’s solution.
The patient should be liberally fed and well hygiened.
Antimon crud is the principal internal remedy.
Others are indicated as follows:
Agaricus musc.- Eruption of small pimples with red areolae and violent itching. Sensation in various parts as if ice cold needles were piercing the skin. In light complexioned persons and drunkards.
Arsen. alb.- In chronic cases. Burning itching, painful after scratching. Great weakness and prostration. Oppression of breathing.
Chinin. ars.- In the diffused form with threatening marasmus. Chronic intestinal derangements.
Iodine.- Small dry, red pimples on the arms, chest and back, with jerking sensation while appearing.
Rough, dry skin. Emaciation. Ravenous hunger.
Kali bichrom.- Papular eruptions on the forearms. Rheumatic pains in the limbs. In fat light complexioned individuals.
Ledum.- Eruption of pimples on the forehead as in brandy drinkers. Eruption of small pimples like red millet seeds over the body. Excessive itching on the backs of both feet, worse after scratching, and by warmth of bed. Relieved after scratching the feet sore.
Nux juglans.- Red pimples on face, neck, shoulders and back. Little tubercles with hard scurf on the in-step.
Potassium iodide.- Lichen on the face and shoulders. Sensitive swelling of the thyroid gland, great general debility.
Sarsaparilla.- Red dry pimples. Burning itching with chilliness.
Staphisagria.- Itching pimply eruption over the face and behind the ears, with rough skin. Burning of the eruption after scratching.
Sulphur iodide.- Red pimples on the nose, chin and arms, with itching. In chronic cases.
To Hebra is due the description of an eruption to which he applied the name above given. It, like lichen planus, is a papular affection, but the papules present a different aspect, and they are acuminate, not flattened. They do not exhibit the central hilum. The papules rarely if ever undergo spontaneous resolution, but persist throughout the entire period of the disease, which, as a rule, terminates with the patient’s death. The papules at first are discrete, and each is decked with a minute adhering scale. New papules continue to form, and in time considerable patches, raised, red, and scaly, come into existence.
The prognosis is essentially grave. A few cases have been reported cured, but in the majority the disease lasted until death terminated the patient’s existence.
Externally we may seek with some measure of success to procure resolution of the lesions by active substitutive treatment, involving the use of iodine, bichloride of mercury, carbolic acid, strong alkaline applications, etc.; but whether either or all of them is capable of retarding the usual termination is problematical.
There are several varieties of lichen given by different authors, but, as they are but forms of either the two above mentioned or lichen simplex, we will omit them, especially as they will be referred to in the description of the various lesions of the skin, and simply give a description of lichen simplex.
One case, reported in one of out journals I would like to mention, as showing the efficacy of a well chosen homoeopathic remedy.
The case, as reported, is as follows:
Cure of Lichen Urticarious by Thuja.
A gentleman brought his fourteen year old son for treatment for a skin affection that had defied two able specialists. He had been treated both internally and externally and strictly dieted- but without effect. The lichen was wont to come periodically in the warm weather; the patient literally tears himself because of the irritation. The rash was much worse on the left side, that being the side on which he was vaccinated. Thuja 30, was ordered in very infrequent doses. The spots continued to appear for a week after taking the powders, then they disappeared and he has remained quite free from them, although eating freely of meat, fish and fruit. It may be remarked that the cure took effect during warm weather, and that the urticarious lumps were described as worse in the warmth.
Lichen simplex includes as its sub-varieties, L. circumscriptus, L. agrius, and L. pilaris.
Lichen simplex is often seen in the summer, sometimes recurring in the same person several times; the papules are flesh-colored, red, smallish, sometimes very minute, and more or less pointed, lasting a week or so, and followed up by the development of others; the papules are usually seen on the back of the hand, the outer aspect of the forearm, the neck, and the thighs. They are accompanied by a good deal of itching. The papules disappear by resorption, and never become vesicles or pustules. This lichen may last for weeks and months. The disappearance of the papules gives rise to a little desquamation. The skin generally is dry and thickened. The disease is rare. L. circumscriptus is the name given to the disease when the papules are collected together into little round or roundish elevated patches; the border of the diseased patches in such cases is well defined and papular, the surface elevated, rough and dry to the feel; its area increases by circumferential enlargement, and its centre presently clears somewhat; there are generally several circles, and their most usual situation is the back of the forearm or the hip; at other times the back of the hand or calf may be affected, or the inside of the thigh. The patches after a while get more or less scaly, or inflamed and cracked, simulating eczema, but never actually discharging; or in consequence of the centre healing, assume a circinate form; but the history, absence of moisture, and the dry red roughened base are distinctive.
Lichen agrius, or the inflamed form of lichen, differs from the above in the presence of secretion, and hence approaches eczema; but it is, as its name implies, an acute, inflamed lichen. The local manifestation consists of clustered or closely packed red papulae, accompanied by intense itching and burning, causing the patient to scratch violently; this in its turn sets up additional irritation, the torn and excoriated papulae are inflamed, and exude a thin fluid; the whole patch thickens, fissures, and becomes covered over with thin scales, not the yellow puriform scales of eczema. Lichen agrius may also arise by inflammation of the chronic stage of any of the other forms of lichen, and not primarily as an acute form. The acute state lasts about ten or fifteen days, the chronic weeks or months; this variety of lichen is observed about the back, neck, legs, arms, and shoulders; it constitutes one aspect of grocers’, bricklayers’, and bakers’ itch. Vesicles and pustules may, however, form; and then there is an inflamed, raised, reddened, excoriated, discharging, fissured patch, the seat of intense and often intolerable itching and burning, made worse by stimulation of all kinds, especially the warmth of bed. The disease either subsides or increases by the development of fresh crops of papulae.
Lichen pilaris.- Occasionally one sees, either alone or in conjunction with ordinary lichen, or other disease where the skin in hyperaemic, little elevations like papulae, which are, however, seated at the hair follicles; the hair in fact piercing the centre of the papule. A distinct lump is felt by the finger. Hyperaemia of the follicular plexus is followed by fibrous deposit outside the follicle, forming a papule.
When this is accompanied by inflammatory deposit, then solid papules at the hair follicles and constitute lichen pilaris.
Lichen pilaris is then ” fibrous inflammation” seated at the upper part of the hair follicles the effusion of plastic lymph taking place around the follicular, walls, and producing, according to its degree, more or less well marked and distinct papulation, each elevation being perforated by a hair. It must not be confounded with pityriasis pilaris, which is merely a desquamation of cuticular cells into, and distending, the hair follicles, preventing the formation of the hair, and producing a blocking up of the follicles, the collected cells forming “a knot” in the upper part of each follicle, a state of things that may occur after pityriasis rubra, or as the result of an inactive state of skin, especially about the thighs, and which latter only needs the free use of soap and water for its removal.
Prognosis.- As a rule, the simple forms get well, with proper treatment, in two or three weeks. L. circumscriptus and agrius are often very obstinate.
Lichen appears to be common in those of nervous temperament and in summer time. It attacks all ages, and is evoked by local and reflex irritation, by a deficiency of alkali in the system; irregularities-mental, physical, alimentative, etc.; hereditary tendency; certain occupations e.g., cooks, bakers, grocers, bricklayers, etc.; hot climates, all seem to be causative factors of this disease.
Diagnosis.- We frequently find some difficulty here. The chief points to remember in regard to lichen are the dry and thickened state of the skin and the presence of papules, which are always to be found, if the disease is in patches, at the extending edge; the hard feel of the papules, and their tingling or itchiness. Lichen simplex and scabies maybe confounded. Lichen is uniform, scabies multiform. In scabies, besides papules there are vesicles, often pustules, and the papules are not so closely aggregated; the eruption also is in the line of flexion, not, as in lichen, in that of extension i.e., lichen is seen chiefly on the outer aspect of the arm; it may occur on the back of the hands and fingers, but it is not interdigital. Lichen simplex never occurs in the feet; it is common on the face; scabies is not. In scabies, too, there is the characteristic vesicle and sillon, whilst the disease is contagious and easily removed by sulphur treatment.
Phthiriasis may simulate lichen, but it is associated with an unhealthy, relaxed, muddy, dirty state of the skin-flabby is the word, the papules (which are pale) are fewer in number and each is marked at its apex with a dark speck (dried blood) effused as the result of scratching. The skin is not thickened and dry, as in lichen, nor is there any attempt at scaliness, as in lichen, not aggregation of papules into patches or groups. Phthiriasis is essentially a disease of advanced age. It occurs in the uncleanly, and there is often a peculiar urticated state of skin, seen very markedly on the back and chest, produced by an exaggeration of the spaces enclosed by the normal furrows. Phthiriasis does not occur about the face; the sensation is one of formication, and is altogether our of proportion to the local disease, whilst pediculi may frequently be detected in the folds of the linen.
Lichen agrius resembles eczema, but the latter is moist and discharging, occurs in delicate and thin not in harsh dry skins; again, the history and edge of the patch in lichen point to the existence of papules; then the patch is much thicker and harsher than in eczema, and wants its thick yellow crusts; the latter in lichen are thin, pretty few, and “flimsy.”
It is important to remember that scabies may be complicated with lichen, and the latter may be set up as the result of irritation in scabies. One sees this state of things very frequently in the hot season- the irritation of a few scabious spots bringing out a pretty general lichen.
Treatment.- The following ointments are sometimes useful:
Rx Chloroform, M.vjjj
Glycerine, 3 j.
White wax ointment, 3vj.
Cyanide of potassium, gr.iv.
M.sig. Apply night and morning.
Rx Carbonate or lead, gr. iv.
Glycerine, 3 j.
Simple cerate, j.
M. Sig. Use as above.
For the itching, the prescription mentioned in lichen planus, or,
Rx Dilute hydrocyanic acid, dr. ss.
Brandish’s solution of potash, dr. j
Rose water, vj.
M. Apply as needed.
One of the following internal remedies will generally be indicated:
Alumina.- Red pimples on the face. Pimples on the neck and back. Intolerable itching of the whole body, especially when becoming heated in bed.
Ammonium mur.- pimples on the back of the hands desquamating next day.
Anantherum.- Red pimples with itching and burning. Scarlet skin with burning.
Antimon crud.- Small red pimples on right shoulder. From digestive derangement.
Arsen. alb.- In chronic cases with burning itching.
Belladonna.- Papular eruption on the hands like lichen agrius.
Bovista.- Red pimples on the foot.
Bryonia.- Pimples on the abdomen and hips.
Castanea vesca.- Several small pimples on the right thigh, back of the left ear, and on the left upper lip.
Caladium.- Pimples on the mons veneris. Soreness of pimples to the touch.
Kreasote.- Forehead covered with pimples the size of millet seeds.
Ledum.- Small pimples like red millet seeds over the whole body. In brandy drinkers.
Mercurius.- Pimples on the labia. Voluptuous itching. Itching changes to burning by scratching.
Nabulus serp.- Pimples on the face about the nose, upper lip and chest with itching.
Natrum carb.- Pimples on the face and lips. White pimples on the nose.
Nux juglans.- Red pimples on the face and neck. Pricking itching.
Plantago.- Hard white flattened isolated papules on the inside of the thigh. Some papules have a red point in the centre.
Phytolacca.- Pimples with itching on the left leg. Worse first part of the night.
Rumex crisp.- Red pimples on calves of the legs, with itching worse immediately after undressing.
Sepia.- Pimples close together on the face. Pimples on the legs, and in the bends of the joints.
Sulphur.- Pimples on inner parts of the thighs. In simple cases.
Sulph. iod.- Red pimples on the nose, chin and arms.
Tilia.- Eruption of small red, rather deeply seated pimples, with violent itching and burning like fire after scratching.
The disease occur essentially in strumous subjects. It shows itself in the form of little elevations about the size of millet seeds either pale, or yellowish, or a brownish-red color. These papules never become vesicles; they are grouped together, sometimes in circles, sometimes in segments of circles. The papules are seated at the hair follicles, and are by-and-by covered by thin scales; the patches itch slightly, but not so much as to be scratched, and hence they are not excoriated.
The patches remain in one one condition a long time, and undergo no changes but exfoliation and involution. The disease is limited to the trunk, the belly, the breast, and back, being rare on the extremities. Its course is very slow. Generally speaking many groups of papules develop at the same time. They soon reach the height of development, and then remain awhile in status quo. In consequence of the absence of local symptoms, the disease exists unnoticed for some time. When at its acme, other symptoms are observed; between the groups, and at the same time, on parts free from lichen – that is, on the extremities and face- more or less numerous isolated bluish-red elevations are developed; these are about the size of lentils, and look very much like common acne; some of the papules are said to contain pus; then by-and-by they wither and disappear, leaving dark pigmented lentil-sized marks in some places whilst in others fresh formations take place. The skin between the diseased patches is the seat of desquamation, the scales being pale and shining, whilst the whole skin may assume a cachectic appearance. In 90 per cent., the disease is observed in markedly scrofulous subjects, and particularly children, together with swelling of the submaxillary, cervical, and axillary glands with caries and necrosis, or tabes mesenterica.
The treatment is the same as for scrofula. Cod-liver oil internally, with inunctions of oil externally is a great aid in treatment of these cases.
The disease is popularly known as the red gum, tooth rash, etc.; some authors look upon it as the lichen of infants. This is wrong, as lichen is an affection of the papillary layer of the derma, about the hair follicles, while strophulus is at the sweat follicles, and is characterized by the appearance of small red or white papules, varying in size from pins’ heads to small millet seeds; they are irregularly dispersed or slightly aggregated, and intermingled with more or less erythema; are attended with itching, sometimes slight moisture, and desquamation. It makes its appearance on the most exposed parts, the face especially but also the neck, arms and limbs, in successive crops. There are two forms of the affection. One variety, mostly due to over- clothing, appears in infants a few weeks old. The other variety is frequently met with during the period of dentition, lasts longer than the former variety, and is often associated with gastro-intestinal disturbance.