European S1 guidelines on the management of lichen planus: a cooperation of the European Dermatology Forum with the European Academy of Dermatology and Venereology

Common diseases of the nail: Diagnosis and therapy

This review focuses on nail changes that do not belong to the group of benign or malignant nail tumors. These common afflictions of the nail include structural changes in and under the nail plate as well as inflammation around and in the nail bed. They include onychomycoses, nail psoriasis, onychodystrophies, subungual hematoma, paronychia, ingrown nails and pincer nails. Due to the peculiar anatomy and physiological growth conditions of the nail, the pathology does not necessarily stem from the site of the clinical problem and calls for careful inspection and interpretation.

Lichen Planus

Lichen planus (LP) is a T cell-mediated disease affecting the stratified squamous epithelia of the skin and/or mucus membrane. Histologically, the disease is characterized by a lichenoid inflammatory infiltrate and vacuolar degeneration of the basal layer of the epidermis. LP has three major subtypes: Cutaneous, mucosal and appendageal LP. Rarely, it may affect the nails in the absence of skin and/or mucosal changes. LP may also be induced by several drugs, typically anti-hypertensive medication or be associated with infections, particularly viral hepatitis. The diagnosis is based on the clinical presentation and characteristic histological findings. Although the disease is often self-limiting, the intractable pruritus and painful mucosal erosions result in significant morbidity. The current first-line treatment are topical and/or systemic corticosteroids. In addition, immunosuppressants may be used as corticosteroid-sparing agents. These, however are often not sufficient to control disease. Janus kinase inhibitors and biologics (anti-IL-12/23, anti-IL17) have emerged as novel future treatment options. Thus, one may expect a dramatic change of the treatment landscape of LP in the near future.

Retrospective analysis of the clinical characteristics and patient-reported outcomes in vulval lichen planus: Results from a single-center study

Vulval lichen planus (VLP) is a rare, but often chronic, inflammatory disease whose symptoms include genital pain, discomfort, and dyspareunia. The clinical manifestations include erythema, erosions, and scarring. The aim of this study was to longitudinally investigate patient-reported outcomes and clinical findings in patients with VLP. Patients (>18 years) with histologically confirmed VLP were included in the retrospective analysis. Patient demographics, clinical features, symptomatology, quality of life, management, clinical outcomes, and comorbidities associated with VLP were analyzed. Twenty-four patients were identified with a mean (standard deviation [SD]) follow-up time of 19.3 (13.8) months. Classical VLP with glazed erythema was found in seven (29.2%) patients, erosive VLP was present in 15 (62.5%) patients, and hypertrophic VLP in two (8.3%). Seven patients had additional cutaneous involvement, while six patients had both vulval and oral mucosal involvement. The labia minora was the most frequently affected anatomical site (83.3%), followed by the clitoris (58.3%). Scarring lesions were found in 62.5% (n = 15) of patients. All study participants received treatment with potent and/or superpotent topical corticosteroids but 50% required systemic therapy (acitretin, corticosteroids, or hydroxychloroquine). Five (20.8%) patients underwent surgery due to adhesions and scarring resulting from VLP. One patient was diagnosed with a vulval squamous cell carcinoma during long-term follow-up. The mean (SD) Dermatology Life Quality Index score was 8.4 (5.5) at presentation and 8.9 (6.8) at the end of follow-up. In conclusion, VLP was associated with moderate quality of life impairments which persisted despite treatment, suggesting that current treatments for VLP are inadequate.

Epigallocatechin-3-gallate exhibits anti-inflammatory effects in a human interface dermatitis model-implications for therapy

BACKGROUND

Epigallocatechin-3-gallate (EGCG) has been proven effective in treating viral warts. Since anticarcinogenic as well as anti-inflammatory properties are ascribed to the substance, its use has been evaluated in the context of different dermatoses. The effect of EGCG on interface dermatitis (ID), however, has not yet been explored.

OBJECTIVES

In this study, we investigated the effect of EGCG on an epidermal human in vitro model of ID.

METHODS

Via immunohistochemistry, lesional skin of lichen planus patients and healthy skin were analysed concerning the intensity of interferon-associated mediators, CXCL10 and MxA. Epidermal equivalents were stained analogously upon ID-like stimulation and EGCG treatment. Monolayer keratinocytes were treated likewise and supernatants were analysed via ELISA while cells were processed for vitality assay or transcriptomic analysis.

RESULTS

CXCL10 and MxA are strongly expressed in lichen planus lesions and induced in keratinocytes upon ID-like stimulation. EGCG reduces CXCL10 and MxA staining intensity in epidermis equivalents and CXCL10 secretion by keratinocytes upon stimulation. It furthermore minimizes the cytotoxic effect of the stimulus and downregulates a magnitude of typical pro-inflammatory cytokines that are crucial for the perpetuation of ID.

CONCLUSIONS

We provide evidence concerning anti-inflammatory effects of EGCG within a human in vitro model of ID. The capacity to suppress mediators that are centrally involved in disease perpetuation suggests EGCG as a potential topical therapeutic in lichen planus and other autoimmune skin diseases associated with ID.

Fractal Dimension and Texture Analysis of Lesion Autofluorescence in the Evaluation of Oral Lichen Planus Treatment Effectiveness

BACKGROUND

Oral Lichen planus (OLP) is a chronic inflammatory disease. Topical steroids are used as the treatment of choice. The alternative is photodynamic therapy (PDT). The study aimed to fabricate optimal biodegradable matrices for methylene blue or triamcinolone acetonide because of a lack of currently commercially available carriers that could adhere to the mucous.

METHODS

The study was designed as a 12-week single-blind prospective randomized clinical trial with 30 patients, full contralateral split-mouth design. Matrices for steroid and photosensitizer and laser device were fabricated. Fractal and texture analysis of photographs, taken in 405, 450, 405 + 450 nm wavelength, of lesions was performed to increase the objectivity of the assessment of treatment.

RESULTS

We achieved two total responses for treatment in case of steroid therapy and one in the case of PDT. Partial response was noted in 17 lesions treated using local steroid therapy and 21 in the case of PDT. No statistically significant differences were found between the effectiveness of both used methods. Statistically significant differences in fractal dimension before and after treatment were observed only in the analysis of photographs taken in 405 + 450 nm wavelength.

CONCLUSIONS

Photodynamic therapy and topical steroid therapy are effective methods for treating OLP. Using a carrier offers the possibility of a more predictable and effective method of drug delivery into the mucous membrane. Autofluorescence enables the detection of lesions especially at the early stage of their development.

A Comparison of Clinical Efficiency of Photodynamic Therapy and Topical Corticosteroid in Treatment of Oral Lichen Planus: A Split-Mouth Randomised Controlled Study

Background: The aim of the study was to compare the effectiveness of photodynamic therapy (PDT) to steroid therapy in the treatment of oral lichen planus (OLP). Due to the lack of commercially available drug carriers, innovative proprietary solutions were used for both the photosensitiser and the steroid carrier—in the first case to shorten and in the second to extend the contact of the active substance with the mucosa. Methods: A prospective, randomised, single-blind, 12-week full contralateral split-mouth clinical trial of 30 patients with bilateral oral lichen planus was conducted. The prepared matrices were incorporated with active substances methylene blue 5% and 0,05% triamcinolone. The size of lesions, Thongprasom, ABISIS, and VAS scale were evaluated. Results: Relatively high rates of complete remission of lichen were demonstrated: immediately after treatment, 33.3% with PDT and 22.2% with triamcinolone (TA), and after 3 months, 54.2% with PDT and 62.9% with TA. After 3 months of treatment, a reduction in the area of evaluated lesions of 52.7% for PDT and 41.7% for TA was achieved. Conclusion: In situations of topical or general contraindications to oral corticosteroids, resistance to them, or the need for repeated treatment in a short period of time, PDT appears to be a very promising treatment option.

Effectiveness of narrowband UVB phototherapy and psoralen plus UVA photochemotherapy in the treatment of generalized lichen planus: Results from a large retrospective analysis and an update of the literature

Background

The aim of this retrospective study was to compare the efficacy and safety of different phototherapeutic modalities in the treatment of cutaneous lichen planus (LP).

Methods

We retrospectively analyzed the chart data of 53 patients with generalized LP who had been subjected to narrowband UVB (NB‐UVB) or photochemotherapy (PUVA) between January 1997 and April 2020. Of these, 30 patients had received NB‐UVB, 18 patients oral PUVA and 5 patients bath PUVA.

Results

Fifty patients completed a full treatment course. The percentage of patients with a complete (>90% clearing) or good (51%‐90% clearing) response was similar for NB‐UVB versus PUVA (86.2% vs. 90.5%; P = 1.00). The number of exposures required for obtaining a complete or good response was also comparable for both treatment groups (NB‐UVB: 28.9 ± 12.3 vs. PUVA: 25.4 ± 10.1; P = .209). Adverse events, in particular gastrointestinal upsets, were recorded in 26.1% of patients treated with oral PUVA while none were observed with NB‐UVB.

Conclusion

The therapeutic outcome and the number of treatments required for achieving a complete or good response were comparable for NB‐UVB and PUVA; however, PUVA therapy was associated with a substantially higher rate of moderate adverse events.

[Current dermatology guidelines in Germany and Europe : A selection of clinically relevant recommendations]

Clinical practice guidelines are systematically developed decision aids for specific medical conditions. In Germany, national dermatology guidelines are developed chiefly under the aegis of the German Dermatological Society in collaboration with the Professional Association of German Dermatologists. European and international dermatological guidelines also exist and are developed by a range of organisations, such as the European Centre for Guidelines Development, which was founded by the European Dermatology Forum in 2018. In the years 2019 and 2020, new or updated German national guidelines were published on topics such as pathological scars (hypertrophic scars and keloids), cutaneous lupus erythematosus, pyoderma grangrenosum, anal pruritus, anal eczema, anal canal and anal rim carcinomas, as well as the prevention of HPV-associated neoplasms through vaccination, syphilis and the systemic treatment of neurodermitis. A new European guideline on lichen planus closes a gap in the spectrum of guidelines available in Germany. Key recommendations and relevant changes in the guidelines are presented in this article.

Lichen planus - a clinical guide

Lichen planus (LP) is a chronic lichenoid inflammatory disorder of the skin, mucosa and of the appendages. LP is classically characterized by the presence of a rich infiltration of inflammatory T cells, which migrate in the upper part of the dermis, arranged in a band-like pattern. Different sub types of the disease have been so far described. Albeit LP is clinically well defined, the disease still represents a therapeutic enigma. Especially with regard to mucosal or scalp affecting LP types, which often present a recalcitrant and treatment unresponsive course, efficacious therapeutic options are still lacking. Thus, LP represents a disease with a high psychosocial burden. Yet, development in the deciphering of LP pathogenesis reveals possible new druggable targets, thus paving the way for future therapeutic options. In this clinical guide, we summarize the current clinical knowledge and therapeutic standards and discuss the future perspective for the management of LP.

[Esophageal Lichen Planus - an Underdiagnosed Disease]

An involvement of the esophagus in patients with lichen planus was described for the first time in 1982. Ever since, it has been seen as a rarity. However, studies over the last 10 years have shown a higher prevalence than expected. It may even be supposed that esophageal lichen planus (ELP) is more common than eosinophilic esophagitis. ELP mostly affects middle-aged women. The principal symptom is dysphagia. Endoscopically, ELP is characterized by denudation and tearing of the mucosa, trachealization and hyperkeratosis and esophageal stenosis may occur in patients with long courses of the disease. Histologic findings including mucosal detachment, T-lymphocytic infiltrate, intraepithelial apoptosis (civatte bodies) and dyskeratosis are crucial. Direct immunofluorescence shows fibrinogen deposits along the basement membrane zone. So far, there is no well-established therapy but a treatment with topic steroids is effective in 2/3 of the patients. Common therapy of lichen planus of the skin seems to be ineffective for treatment of ELP. Symptomatic esophageal stenosis should be endoscopically dilated. ELP joins the group of "new" immunologic diseases of the esophagus.

Interventions for oral lichen planus: A systematic review and network meta-analysis of randomized clinical trials

BACKGROUND

Corticosteroids, calcineurin inhibitors, vitamin D, photodynamic therapy, herbal drugs are some of the interventions tried in clinical trials for treating oral lichen planus. We carried out the present network meta-analysis to compare the above-mentioned interventions.

METHODS

Electronic databases were searched for randomized clinical trials evaluating interventions in patients with symptomatic oral lichen planus. Clinical resolution, clinical score, pain resolution, pain score, and adverse effects were the outcomes evaluated.

RESULTS

Fifty-five (2831 patients) trials were included. Corticosteroids (OR: 13.6; 95% CI: 1.2, 155.4), pimecrolimus (OR: 14.7; 95% CI: 1.7, 125), purslane (OR: 18.4; 95% CI: 3.5, 97), and ozonized water/corticosteroids (OR: 52; 95% CI: 1.4, 1882.6) had better rates of clinical resolution compared to placebo. Corticosteroids (OR: 3.18; 95% CI: 1.2, 8.43), ozonized water/corticosteroids (OR: 9.9; 95% CI: 2.7, 36.2), aloe vera (OR: 13; 95%: 1.5, 111.8), pimecrolimus (OR: 18.8; 95% CI: 2, 177.4) and hyaluronic acid (OR: 24.8; 95% CI: 1.3, 457.6) were significantly associated with superior rates of pain resolution compared to placebo. Pimecrolimus and cyclosporine were associated with significantly higher risk of adverse effects than placebo.

CONCLUSION

Topical corticosteroids were the most effective drug class for treating oral lichen planus.

The inflammation in cutaneous lichen planus is dominated by IFN-ϒ and IL-21-A basis for therapeutic JAK1 inhibition

Cutaneous lichen planus (CLP) and psoriasis (PSO) are both common chronic inflammatory skin diseases for which development of new treatments requires the identification of key targets. While PSO is a typical Th17/IL-17-disorder, there is some evidence that Th1/IFN-ɣ dominate the inflammatory process in CLP. Nonetheless, the immunopathogenesis of CLP is not fully explained and key immunological factors still have to be recognized. In this study, we compared the immune signature of CLP lesions with the well-characterized inflammation present in PSO skin. First, we analysed the histological and immunohistological characteristics of CLP and PSO. Second, we assessed the cytokine expression (IL1A, IL1B, IL4, IL6, IL8, IL10, IL17A, IL19, IL21, IL22, IL23A, IL13, IFNG, TNF, IL12A, IL12B and IL36G) of lesional skin of CLP with PSO by qPCR. Histology revealed a similar epidermal thickness in CLP and PSO. Immunohistochemically, both diseases presented with an inflammatory infiltrate mainly composed by CD3⁺ CD4⁺ T cells rather than CD3⁺ CD8⁺ . Importantly, mRNA analysis showed a distinct cytokine signature: while levels of IL12B, IL1A, IL6 and IL23 were similar between the two groups, the characteristic PSO-associated cytokines IL8, IL17A, IL22, IL19 and IL36G were expressed at very low levels in CLP. In contrast, CLP lesional skin was dominated by the expression of IFNG, IL21, IL4, IL12A and TNF. Immunohistochemistry confirmed the dominance of IL-21, IFN-ɣ and also pSTAT1 in the dermal infiltrate of CLP, while IL-17A was more present in PSO. Collectively, this study improves our understanding of the immunological factors dominating CLP. The dominating cytokines and signalling proteins identified suggest that anti-cytokine therapeutics like JAK inhibitors may be beneficial in CLP.

Clinical and Penile Dermoscopy Evaluation of a Reticulated Pattern on the Penile Glans

A 32-year-old man visited our clinic for evaluation of a mildly pruritic lesion on the glans. He complained of a recurrent red patch, which had been slowly enlarging over the previous three months. Clinical examination revealed a slightly raised plaque with a reticulated lacy net pattern and white threads on the glans. There was no evidence of skin, nail or other mucosal involvement on physical examination. Laboratory tests, including hepatitis and syphilis serologies, were normal or negative. Penile dermoscopy revealed white reticular and circular lines [Wickham striae] on a red background. Penile dermoscopy should be included as a part of the clinical inspection of genital diseases to support diagnosis, as well as to ideally avoid unnecessary invasive investigation.