Comparison of systemic mycophenolate mofetil with topical clobetasol in lichen planopilaris: a parallel-group, assessor- and analyst-blinded, randomized controlled trial

Lichen Planus: What is New in Diagnosis and Treatment?

Lichen planus (LP), an idiopathic, multifaceted chronic inflammatory disease with a heterogeneous clinical presentation, affects approximately 0.5-1% of the population. The various clinical manifestations of LP fall into three broad categories, namely cutaneous, appendageal, and mucosal, with further subclassification depending on the morphology and distribution patterns of individual lesions. There is mounting evidence that LP has systemic associations, including autoimmune conditions, glucose intolerance, dyslipidemia, and cardiovascular disorders. Cutaneous hypertrophic and mucosal forms of LP are at a heightened risk for malignant transformation. Familiarity with these potential associations in conjunction with long-term follow-up and regular screening could lead to a timely diagnosis and management of concomitant conditions. In addition, the frequent quality of life (QoL) impairment in LP underscores the need for a comprehensive approach including psychological evaluation and support. Several treatment strategies have been attempted, though most of them have not been adopted in clinical practice because of suboptimal benefit-to-risk ratios or lack of evidence. More recent studies toward pathogenesis-driven treatments have identified Janus kinase inhibitors such as tofacitinib, phosphodiesterase-4 inhibitors such as apremilast, and biologics targeting the interleukin-23/interleukin-17 pathway as novel therapeutic options, resulting in a dramatic change of the treatment landscape of LP. This contemporary review focuses on the diagnosis and management of LP, and places emphasis on more recently described targeted treatment options.

Platelet-rich plasma as a new and successful treatment for lichen planopilaris: A controlled blinded randomized clinical trial

INTRODUCTION

Lichen planopilaris (LPP) is one of the most common causes of scarring hair loss caused by immune-mediated inflammation resulting in atrophy and scaling. The key to preventing this irreversible hair loss is diagnosing and starting treatment at the earliest possible stage. As there is no definite cure for LPP, the therapy could be challenging. In the study, we conducted a single-blinded randomized clinical trial to evaluate the therapeutic effects, safety, and tolerability of platelet-rich plasma versus topical clobetasol in the treatment of LPP.

METHOD

A randomized single-blinded controlled clinical trial was conducted in 24 LPP patients referring to our dermatology clinic between August 2022 and March 2023. Patients in the control group were treated with topical clobetasol 0.05% applied at night, and patients in the case group, in addition to topical clobetasol, received three sessions of PRP injection monthly. Both groups were assessed 1, 2, and 6 months after the start of the study by the Lichen Planopilaris Activity Index (LPPAI), physician and patient satisfaction, tolerability, and recording adverse effects.

RESULTS

The average age in the clobetasol and PRP groups was 43.75 ± 13.51 and 42.75 ± 9.67, respectively (p = 0.83). In terms of gender, all 12 cases (100%) in the clobetasol group and 9 cases (75%) in the PRP group were female (p = 0.21). Both PRP and topical clobetasol effectively reduced LPPAI in the first 2 months; however, after 6 months, the LPPAI significantly increased in the clobetasol group (p = 0.001). There were no significant differences in LPPAI between the two groups at the beginning of the study and after 1 month. However, the mean LPPAI score in the clobetasol group was significantly higher than in the PRP group at 2 and 6 months after the start of the study (p = 0.01). Patient satisfaction with treatment increased in both groups during follow-up sessions, but at the end of the follow-up period, it was significantly higher in the PRP group (p = 0.03). Finally, the study did not have any serious adverse effects, and the pain experienced during PRP injection was tolerable for the patients. Overall, treatment tolerability was excellent in both groups.

CONCLUSION

Given the different efficacy profiles, PRP could be considered a new and effective choice for the treatment of LPP.

Efficacy and safety of tofacitinib for treatment of alopecia areata in children: A systematic review and meta-analysis

BACKGROUND

Tofacitinib, a potent JAK inhibitor, has gained increasing interest, in recent years, among dermatologists for the management of refractory alopecia areata. Despite a growing number of studies on its safety and efficacy, there is still a lack of clarity, especially in the pediatric population, in treatment considerations such as proper dosage, treatment duration, side-effect profile, and therapeutic strategies to guide clinicians.

METHODS

Multiple databases were systematically searched. Following the PRISMA diagram, of a pool of 601 papers, seven met a checklist of inclusion criteria. These were observational studies including a total of 59 patients from four to 19 years of age.

RESULTS

In the evaluated studies, tofacitinib was administered either orally at a 2.5 to 15 mg daily (mostly 5 mg twice a day) dosage for 2 to 38 months or in the form of a 2% topical solution for 3-17 months. Metanalysis showed that 49% (95% CI: 29%-69%, I²  = 59.94%) of patients experienced a reversal of alopecia after a minimum of 3 to 9 months of therapy. Fifty-five percent (95% CI: 23%-86%, I²  = 75.07%) and 41% (95% CI: 23%-59%, I²  = 0.00%) showed Good/complete and partial response rates, respectively. Oral administration was significantly more efficacious than topical application (73% vs 23%, p-Value = 0.04). Few side effects such as diarrhea and mild liver transaminases abnormalities were noted in several patients.

CONCLUSION

Results of this review suggest that tofacitinib at 2.5-15 mg daily (especially 5 mg twice daily) oral formulation or 2% topical solution can be regarded as a viable alternative or adjunct to the conventional treatment options for moderate to severe forms of alopecia areata in children owing to its acceptable efficacy and side-effect profile. However, uncertainties continue to exist around treatment strategies including initial and maintenance dosages, route of administration, dose adjustments, the timing of tapering or discontinuation, and associated treatment modalities.

COVID vaccine recommendations in dermatologic patients on immunosuppressive agents: Lessons learned from pandemic

BACKGROUND

Since SARS-CoV2 vaccines were approved without enough long-term monitoring due to emergent situations, some issues have been raised about timing and protocol of receiving them by patients treated by different immunosuppressive agents.

AIM AND METHOD

Here, we present different aspects of SARS-CoV-2 vaccination in such patients in the field of dermatology.

RESULT

In brief, SARS-CoV-2 vaccination is recommended in all dermatologic patients, regardless of their disorders and therapeutic regimens. Nevertheless, special considerations should be given to the immunosuppressive therapy and its association with vaccination timing due to the decreased immunogenicity of vaccines in this setting.

CONCLUSION

Novel biologic immunotherapies are advantageous over conventional systemic therapies not only in their safety and selective functions but also in this aspect that many of them do not affect vaccines immunogenicity.

Comparative Efficacy Study Combination of Oral Methotrexate and Prednisolone versus Oral Methotrexate in Patients with Lichen Planopilaris

Background

Lichen planopilaris (LPP) is a rare inflammatory disorder of the scalp that causes cicatricial alopecia. No therapeutic approach has been approved for this disease due to the rare frequency. Methotrexate and corticosteroid are commonly considered second- or third-line therapy. The efficacy of a combination of methotrexate and corticosteroid has been reported in some dermatological and immunological diseases. However, the efficacy of this combination in LPP is not clear. Therefore, this study aimed to compare the impact of methotrexate alone and in combination with corticosteroid on LPP.

Materials and Methods

This randomized clinical trial was performed on 28 patients who referred to the dermatology clinic affiliated with Isfahan University of Medical Sciences, Isfahan, Iran during February 2015-December 2016, and 24 of them completed the trials. Fourteen patients received 15 mg methotrexate per week alone and the other fourteen subjects received 200 mg prednisolone plus 15 mg methotrexate per week. The primary outcome was Lichen planopilaris activity index (LPPAI) score. Moreover, we evaluated photographic changes and symptoms during the study.

Results

The mean of LPPAI in both groups decreased during the follow-up with a similar pattern of LPPAI changes in both groups. No statistically significant difference was found between the two intervention groups regarding the LPPAI score. We found no difference in the symptoms and photographic assessments in methotrexate and combination therapy groups during follow-up. In both groups, exclusively one adverse effect was reported.

Conclusions

Our results showed that methotrexate therapy with and without corticosteroids had similar efficacy and safety.

Efficacy, safety, tolerability, and satisfaction of N-acetylcysteine and pentoxifylline in lichen planopilaris patients under treatment with topical clobetasol: A triple arm blinded randomized controlled trial

Lichen planoplaris (LPP) is one of the most common causes of inflammatory cicatricial alopecias. There is no definitive cure for the disease and most of the available therapeutic options can potentially lead to serious complications following their use for extended durations. In this study, we aimed to evaluate the efficacy, safety and tolerability of N-acetylcysteine (NAC) and pentoxyfillin (PTX), as adjunctive therapies, in the management of LPP. In a randomized, assessor- and analyst-blinded controlled trial, patients with proven LPP were randomly assigned to three groups of 10. Group I (the control group) received clobetasol 0.05%lotion; Group II, a combination of clobetasol 0.05% lotion and oral PTX; Group III, a combination of clobetasol lotion 0.05% and oral NAC. Lichen planopilaris activity index (LPPAI), the possible side effects, tolerability and patients satisfaction were assessed before and two and four months after the initiation of the treatments. Thirty patients, 96.7% women, with a mean age of 46.8 ± 13.3 years old, were included in the study. Four months into the treatments, the overall LPPAI and the severity and/or frequency of most of its determinants significantly decreased in all groups. In a comparison among the groups, patients who received either of the combination therapies showed more decline in their LPPAI than those receiving only clobetasol. The decline was more noticeable and statistically significant only in the NAC group. Three patients in the PTX group developed complications that were not statistically significant when compared with the other groups. There were no substantial differences in the tolerability of the treatments among the study arms. The use of oral NAC and PTX added to the therapeutic efficacy of topical clobetasol in the treatment of LPP, suggesting that they might be beneficial and safe adjuvant therapies and add to the efficacy of topical treatment without any noticeable impact on the adverse effects experienced by patients.

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.

A systematic review on the treatment of pediatric severe alopecia areata by topical immunotherapy or Anthralin (contact sensitization) or low-level light/laser therapy (LLLT): focus on efficacy, safety, treatment duration, recurrence, and follow-up based on clinical studies

INTRODUCTION

Alopecia areata (AA) in its extensive and severe forms is treatment-challenging, especially in pediatrics.

METHOD

A PRISMA-compliant systematic review of seven electronic databases was searched by the terms "alopecia areata," "pediatric," "topical immunotherapy," "Anthralin," and "light therapy" from inception until March 2021. All the alternative names of the disease and therapies have been included in the search terms. 790 articles went to title abstract review by two independent reviewers. In the subsequent level, a review of the full text of studies was conducted.

RESULTS

Finally, 10 relevant articles in terms of content structure, subject coverage, and purpose, were selected for further review. The highest percentages of complete hair regrowth were 79.6% and 63.61% by SADBE (topical immunotherapy) and laser therapy. By Anthralin (contact sensitization), the complete response rate was below 50% (between 30 and 35%). Regarding average response, the most effective methods were local immunotherapy (with an average effectiveness of 53.8%), laser therapy (52.55%), and the use of Anthralin-induced contact dermatitis (30.86%), respectively. However, recurrence rate-after treatment with induced contact dermatitis by topical medications like Anthralin (contact sensitization)-was lower (mean 43.53%) in comparison with local immunotherapy (57%). In topical immunotherapy, light base therapy, and contact sensitization, the highest percentage of complete hair regrowth and the average response rate were (63.61% and 52.55%), (79.6% and 53.8%) and (32% and 30.8%), respectively. These methods are considered safe in children.

CONCLUSION

A high and more than 50% efficacy in hair regrowth could be expected by topical immunotherapy and light/laser therapy method. No serious side effects have been observed by these methods that are well tolerated in children. Therefore, a combination of local immunotherapy and light/laser therapy could be suggested for the treatment of extensive AA in children. The use of Anthralin could be associated with a lower but more durable response. These points are important for patient selection in individualized situations.

Scarring Alopecia With Coexisting Lichen Planus in a Child: A Rare Phenomenon

Lichen planopilaris (LPP) is characterized by chronic cicatricial alopecia that is lymphocytic in nature. The underlying pathophysiology of LPP is not well understood. Failure of therapeutic management occurs quite often resulting in significant psychosocial stress on the patient when they are unable to prevent further hair loss or reverse it. Although the occurrence of LPP is rare, it is especially seldom observed in the pediatric population. Herein, we discuss a case of a nine-year-old child who was recently diagnosed with LPP.

The healing effects of facial BOTOX injection on symptoms of depression alongside its effects on beauty preservation

BACKGROUND

Beauty is closely associated with a sense of calm, confidence, and hope for a better life. Therefore, it is expected that improving the appearance or even correcting one's view of appearance can prevent depression and even improve different degrees of depression in individuals.

AIMS

Investigation of whether using botulinum injections (a common method of improving facial esthetics) can improve the degree of depression in clients.

METHODS

This prospective interventional before-after study was conducted on 121 consecutive individuals referred for beautifying the face. Before performing the interventional procedure by facial botulinum injection as well as one month later, the depression status was examined by the Beck Depression Inventory II (BDI) questionnaire.

RESULTS

The mean baseline depression score dropped from 18.9 ± 4.8 to 10.6 ± 2.9 during the follow-up time (P < .001). Using the multivariable linear regression modeling and with the presence of baseline parameters, the main determinants of improving depression score included young ages (beta = -0.541, P = .001), higher educational level (beta = 0.595, P = .015), and previous experiences of botulinum toxin use (beta = 1.072, P = .036).

CONCLUSION

The improvement in people's moods along with correction of their facial defects following botulinum toxin injections would be expected.

Systematic review of platelet-rich plasma in treating alopecia: Focusing on efficacy, safety, and therapeutic durability

Considering the different forms, alopecia could be a very common condition with particular therapeutic concerns; thus, recent therapies still require further assessments. Aim of this systematic review was to evaluate efficacy, safety, and therapeutic durability of platelet rich plasma (PRP) in treating various forms of alopecia. A total of 64 articles were found through a systematic search, and eight original articles were included in the study, based on inclusion/exclusion criteria. In most studies (62.5%) patients' conditions had improved by receiving PRP therapy; these cases experienced an increase in growth and thickness of hair. Simultaneous use of PRP and Minoxidil demonstrated the highest rate of improvement and satisfaction. The highest efficacy in patients with alopecia areata was 76% and the lowest efficacy was 31.7% and in patients with androgenetic alopecia the highest efficacy was 42.75% and the lowest reported efficacy was 25.55%. The main side effect was pain due to PRP injection, which disappeared after ending the treatment and only one article reported more serious side effects. Recurrence after treatment was also reported in only one article. PRP is a safe and easy method for treating hair loss and has limited adverse effects. Optimization of this method depends on dosage, number of sessions and their intervals, and injection techniques. According to the results, the use of PRP due to its relatively high efficiency, low and tolerable side effects, and low recurrence rate can be a good method for the treatment of alopecia and hair loss.

The efficacy and safety of oral low dose naltrexone versus placebo in the patients with lichen planopilaris: a randomized controlled clinical trial

Background and objectives: Lichen planopilaris (LPP) is one of the important causes of cicatricial alopecia. We aimed to evaluate the efficacy and safety of low-dose naltrexone (LDN) in the setting of a clinical trial in patients with LPP.Methods: We included patients with LPP between 2018 and 2020. Patients were allocated to two groups. The first group received topical clobetasol plus oral low dose naltrexone (3 mg) while the second received topical clobetasol plus placebo. The assessment was made for the disease severity by lichen planopilaris activity index (LPPAI) instrument and the safety of the drug in 2-month intervals up to 6 months. To compare both groups, we used the ANOVA test for repeated measures. Clinical trials registry code: IRCT20180809040747N1.Results: Thirty-four patients were analyzed in an intention-to-treat fashion. There was a decrescendo pattern on LPPAI scores that was statistically significant within the LDN (p = .001) but almost significant within the placebo group (p = .060) and non-significant between the groups (p = .813). The side effects attributable to the low dose naltrexone was not statistically different between studied groups.Conclusion: Low-dose naltrexone (3 mg) failed to improve the severity of the LPP more than what is achievable with topical clobetasol.

Mycophenolate mofetil and lichen planopilaris: systematic review and meta-analysis

BACKGROUND

For severe cases of lichen planopilaris (LPP), unresponsive to first line therapy, systemic or potent agents may be required for disease control. There have been several reports of the off-label use of mycophenolate mofetil (MMF) in patients with LPP or have developed adverse effects to initial agents.

METHODS

A systematic review and meta-analysis was performed according to recommended Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies with ≥5 cases reporting the outcomes of MMF in LPP were pooled and a meta-analysis of proportion was performed. Case reports were excluded from analysis.

RESULTS

A total of six studies were identified and included for meta-analysis, comprising 94 LPP patients. The pooled proportion of any good response (partial or complete) was 69.2% (95% confidence interval (CI): 47.8-77). The pooled proportion of complete response was 20% (95% CI: 10.1-36.3). The pooled proportion of partial responses was 49.2% (95% CI: 30.5-63.7). Side effects occurred in 16.9% (95% CI: 17.6-33.2). of cases, which included elevated LFTs, edema, hyperlipidemia, anemia, herpes zoster infection, photosensitivity, and urinary tract infection.

CONCLUSION

The current evidence for MMF remains limited. However, it appears to be a potential treatment option for patients with severe or recalcitrant LPP who have failed hydroxychloroquine and other immunosuppressants.

Frontal fibrosing alopecia: An update on the hypothesis of pathogenesis and treatment

Frontal fibrosing alopecia (FFA) is a relatively new scarring alopecia that is considered a variant of lichen planopilaris (LPP) with no recognized promising treatments. In this study, we tried to clarify the underlying signaling pathways and their roles in the pathogenesis and progression of FFA. Because of several differences in clinical manifestations, response to treatments, and pathological findings, these two conditions could be differentiated from each other. Taking into account the already discussed signaling pathways and involved players such as T cells, mast cells, and sebaceous glands, different possible therapeutic options could be suggested. In addition to treatments supported by clinical evidence, such as 5 alpha-reductase inhibitors, topical calcineurin inhibitors, hydroxychloroquine, peroxisome proliferator-activated receptor gamma agonists, and oral retinoid agents, various other treatment strategies and drugs, such as phototherapy, Janus kinase inhibitors, dehydroepiandrosterone, sirolimus, cetirizine, and rituximab, could be suggested to mitigate disease progression. Of course, such lines of treatment need further evaluation in clinical trials.

Lichen planopilaris: retrospective study on the characteristics and treatment of 291 patients

Lichen planopilaris (LPP) is an immune-mediated cicatricial alopecia. The main clinical presentations of LPP include classic form, frontal fibrosing alopecia (FFA), and Graham-Little-Piccardi-Lassueur syndrome (GLPLS). We reviewed medical records of all 291 patients diagnosied with LPP from 2006 to 2017 in Department of Dermatology, Tehran University of Medical Sciences. LPP was more common in women than men. Lichen planus (LP) was seen in 59 of patients (20.3%). Parietal lesions (69.75%), frontal (27.14%), occipital (23.71%), and temporal (21.64%) were frequently seen in LPP patients. However, trunk hair involvement (15.4% vs. 2.7%; p = .011) and eyebrow involvement (57.7% vs. 0%; p < .0001) were high in FFA patients. The response rates of cyclosporine (CSP) and methotrexate (MTX) were highest, 100% and 85%, respectively. Those treated with CSP achieved partial remission (PR) and complete remission (CR) faster than MTX-treated group. Moreover, MTX was more effective than MMF but not different in time to reach PR (p = .23) or CR (p = .56). However, CSP and MTX were less safe compared with MMF. 5-alpha reductase inhibitors, systemic retinoids (isotretinoin) or their combination were the most effective therapeutic options for FFA patients.

Ulcerating Lichen Planopilaris - Successful Treatment by Surgery

Lichen planus is a T-cell mediated autoimmune disorder affecting the skin and mucous membranes. Ulcerating lichen planus is uncommon mostly on oral and genital mucosa but not skin. Lichen planopilaris, however, is a subtype of lichen planus affection hair follicles and leading to permanent scarring alopecia. We report a case of lichen planopilaris of the scalp with multiple alopecic patches ulceration – a hitherto unreported clinical feature. The patient was treated surgically, and the defect could be closed by combined tissue advancement and extension.

Clinical Efficacy and Safety of Methotrexate versus Hydroxychloroquine in Preventing Lichen Planopilaris Progress: A Randomized Clinical Trial

BACKGROUND

Lichen planopilaris is an inflammatory cicatricial alopecia, and its management is a challenge for dermatologists. We aimed to compare the efficacy of methotrexate and hydroxychloroquine on refractory lichen planopilaris.

METHODS

In a randomized clinical trial, 29 patients were randomly allocated to receive either 15 mg methotrexate/week or 200 mg hydroxychloroquine twice a day for 6 months. Side effects, symptoms/signs, and laboratory tests were assessed periodically. Lichen Planopilaris Activity Index (LPPAI) was measured before intervention and at 2, 4, and 6 months after. The changes from baseline to the end of the study were analyzed within each group and between the two groups by per-protocol and intention-to-treat analysis.

RESULTS

After 2 months, mean (standard deviation [SD]) decrease in LPPAI in methotrexate group was significantly more than that in hydroxychloroquine group (1.68 [1.24] vs. 0.8 [0.71], respectively, P = 0.047). Furthermore, after 6 months, mean (SD) decrease in LPPAI in methotrexate group was significantly higher than that in hydroxychloroquine group (3.3 [2.09] vs. 1.51 [0.91], respectively, P = 0.01). The following symptoms/signs showed significant improvements in frequency and/or severity in methotrexate group after intervention: pruritus (P = 0.007), erythema (P = 0.01), perifollicular erythema (P = 0.01), perifollicular scaling (P = 0.08), spreading (P = 0.001), and follicular keratosis (P = 0.04). In hydroxychloroquine group, only erythema (P = 0.004) showed significant improvement.

CONCLUSIONS

Methotrexate was more effective than hydroxychloroquine in treating refractory lichen planopilaris.