Drug-induced lichen planus
Question:
Reviewed: 10/2/2026
5/12/2020
I was referred a patient (67 year-old F) with a 5 month history of localized, pruritic rash. The patient was evaluated first by dermatology (3 months into her course). Initial rash description included, “left neck and chest, 5 x 3 cm blanching erythematous plaque”. Dermatology’s differential included eczema vs fixed drug reaction. Skin biopsy demonstrated lichenoid dermatitis with eosinophils (drug-induced lichen planus). Patient recommended to stop atorvastatin (had been taking daily for more than a decade) and started on topical triamcinolone. After 3 weeks of holding the atorvastatin, the patient contacted her PCP and reported no change in pruritus and only slight fading of rash coloration. She was then referred to my office.
The medication list was reviewed carefully. No use of ACE inhibitors, thiazide diuretics, antimalarial, beta blocker, or check point inhibitors. Does take a baby aspirin and had recently re-started this medication AFTER the rash onset. Takes fluoxetine daily for OCD management. Over-the-counter medications include daily loratadine, fluticasone propionate nasal spray, and calcium + vitamin D supplement. No herbal medications. The medical literature reports that this reaction may occur within weeks to even a year or more after starting the offending drug, and it may resolve between weeks to several months after stopping the offending drug. Treatment with a superpotent topical corticosteroid (i.e. clobetasol propionate 0.05% ointment) for 2-4 weeks has been suggested for patients who cannot stop the offending drug or who have symptomatic disease.
Can any insight be provided for the likely culprit? Should a longer trial (>3 weeks) off of atorvastatin be recommended? Should we pursue a trial off of aspirin and/or fluoxetine? If so, what length should the trial(s) be? Should the patient be directly started on treatment with a superpotent topical corticosteroid? And, if refractory to this treatment, would other treatment options should be considered?
Answer:
Lichenoid drug eruptions can have a mean latent period of one year from the start of a new medication and the onset of the skin rash. This long interval can make identification of the trigger difficult. In addition to the medications that you mentioned, vaccines and statins have been reported to cause this condition. I found a recently published case report of atorvastatin-induced lichenoid drug eruption with a review of statin-induced skin eruptions. This paper provides descriptions for 7 patients, including time to remission after cessation of statin therapy (as long as 9 months) and specific treatments that have been used (potent topical steroids, systemic steroids and in one case psoralen and UV A radiation therapy).
After resolution, re-administration of the medication, or another from the same class, generally results in recurrence of the rash, thereby confirming the culprit. While doing so is not necessary, it may be helpful.
Reference:
Forouzan P, Riahi RR and Cohen PR. Atorvastatin-induced lichenoid drug eruption: a case report and review of statin-associated cutaneous adverse events. Cureus. 2020 Mar; 12(3):e7155. PMID: 32257699
Jacqueline A. Pongracic, MD, FAAAAI