Treatment of cutaneous lichen planus (Part 1): A review of topical therapies and phototherapy

Evaluating the Appropriateness of Existing Health-Related Quality of Life Measures in Lichen Planus

INTRODUCTION

Lichen planus (LP) is an inflammatory skin disorder that can present in various forms across the body, including lesions on the skin (cutaneous LP [CLP]), scalp (lichen planopilaris [LPP]) and mucosal regions (mucosal LP [MLP]). Several existing patient-reported outcome measures (PROMs) were identified for potential use in LP clinical development programs. This study aimed to assess the content validity and psychometric measurement properties of the Dermatology Life Quality Index (DLQI), Epworth Sleepiness Scale (ESS), Scalpdex and Oral Lichen Planus Symptom Severity Measure (OLPSSM) in an LP population.

METHODS

Patients completed the PROs at various time points as part of an international Phase 2 clinical study in adults with MLP (n = 37), LPP (n = 37) and CLP (n = 37). Test-retest reliability, construct validity and sensitivity to change were assessed. In addition, qualitative cognitive debriefing interviews were conducted with adults with MLP (n = 20), LPP (n = 19) and CLP (n = 19) in the USA and Germany to examine the PROM content validity.

RESULTS

The DLQI demonstrated adequate reliability and validity, although its ability to detect change was modest and most items were considered not relevant in qualitative interviews. The ESS had good reliability but limited evidence of validity and ability to detect change. Conceptual relevance varied according to the qualitative interview data. The Scalpdex was miscellaneous across domains, but the 'Symptoms' domain performed well overall. Overall, Scalpdex concepts were reported as relevant by most LPP patients interviewed. The OLPSSM demonstrated good psychometric properties and strong evidence of content validity.

CONCLUSIONS

The psychometric and qualitative findings support the use of the OLPSSM and Scalpdex within specific LP subtypes but cautioned use of the DLQI. Administration of the ESS is not recommended in LP because of its poor psychometric performance. Given these limitations, further validation of non-specific disease measures is needed and/or the development of additional LP-specific PROMs.

TRIAL REGISTRATION

NCT04300296.

Patient Experience of Lichen Planus: A Qualitative Exploration of Signs, Symptoms, and Health-Related Quality of Life Impacts

INTRODUCTION

Lichen planus (LP) is an inflammatory skin disorder that can present in various forms across the body, including lesions on the skin (cutaneous LP [CLP]), scalp (lichen planopilaris [LPP]), and mucosal regions (mucosal LP [MLP]). Qualitative exploration of the patient experience of LP, notably symptoms and impacts on health-related quality of life (HRQoL), is limited. A scarcity of research was also identified relating to emotional wellbeing impacts of CLP patients. Two qualitative studies were conducted with LP patients to address these gaps.

METHODS

Study 1 consisted of exit interviews conducted with a subset of adult patients with MLP (n = 5), CLP (n = 4), and LPP (n = 4) enrolled in an LP clinical study in the United States (US) to explore the patient experience. Study 2 consisted of independent qualitative interviews conducted with adult CLP patients (n = 13) from the US and Germany to further explore impacts on emotional wellbeing.

RESULTS

Exit interviews found that itch , pain, and skin lesions were most frequently reported as signs/symptoms of LP. Itch and skin lesions were experienced across all LP subtypes, while pain was only reported by CLP and MLP patients. These signs/symptoms impacted HRQoL including emotional wellbeing (frustration, embarrassment), daily activities (oral hygiene, clothing options), social functioning (intimacy, social activities), and physical functioning (chewing/swallowing, opening/moving mouth). Impacts on activities of daily living (ADL) and physical functioning were mostly experienced by MLP patients. Independent qualitative interviews, which further explored impacts of CLP on patients' emotional wellbeing, identified frustration, worry, sadness, embarrassment, and depression as the most frequently experienced.

CONCLUSION

The findings contribute to the literature by providing qualitative insights into signs/symptoms and HRQoL impacts of LP, from the adult patient perspective. The findings also highlight the importance of considering assessment of HRQoL impacts in future clinical LP research, particularly impacts on emotional wellbeing when selecting instruments for assessment of HRQoL in the CLP population.

TRIAL REGISTRATION

NCT04300296.

Lichen planus in Deutschland - Epidemiologie, Behandlung und Komorbidität. Eine retrospektive Krankenkassendatenanalyse

HINTERGRUND UND ZIELE

Lichen planus (LP) ist eine chronisch entzündliche Hauterkrankung, die eine große Belastung für die betroffenen Patienten darstellt. Es liegen jedoch nur wenige Daten zu dieser Erkrankung vor. Ziel dieser Studie ist es, das Wissen über die Epidemiologie und die Behandlungsmuster des LP anhand von Abrechnungsdaten deutscher Krankenkassen zu erweitern.

PATIENTEN UND METHODEN

Diese retrospektive Beobachtungsstudie nutzte die InGef-Forschungsdatenbank. Es wurden prävalente und inzidente LP-Patienten aus den Jahren 2015 und 2018 identifiziert. Für demografische Charakteristika, Behandlungsmuster und Komorbidität wurden deskriptive Statistiken berechnet.

ERGEBNISSE

Die Prävalenz des LP lag bei 95,9 und die Inzidenz bei 20,1 pro 100 000 Personen im Jahr 2018, was 79 605 prävalenten LP-Fällen in Deutschland entspricht. Die erste LP-Diagnose wurde in der Regel von einem Dermatologen oder Hausarzt gestellt. Drei Viertel der inzidenten und die Hälfte der prävalenten Patienten erhielten eine topische Therapie, meist ohne zusätzliche systemische Therapie. Die Komorbidität des LP stand im Einklang mit bereits bekannten Assoziationen.

SCHLUSSFOLGERUNGEN

Die verfügbaren Therapieoptionen sind nach wie vor begrenzt, was den ungedeckten Bedarf an sicheren und wirksamen systemischen Behandlungsmodalitäten unterstreicht. Der LP ist häufig mit klinisch relevanter systemischer Komorbidität verbunden. Zusammengenommen könnten diese Beobachtungen zu einem verbesserten Verständnis der Krankheitslast führen und das diagnostische Bewusstsein für diese Erkrankung unter Klinikern schärfen.

Lichen planus in Germany - epidemiology, treatment, and comorbidity. A retrospective claims data analysis

BACKGROUND AND OBJECTIVES

Lichen planus (LP) is a chronic inflammatory skin disease and is a major burden for affected patients. However, data on this condition are scarce. This study aims to expand the knowledge on the epidemiology and treatment patterns of LP using German health claims data.

PATIENTS AND METHODS

This retrospective observational study was based on the InGef research database. Prevalent and incident LP patients were identified in the years 2015 and 2018. Descriptive statistics were calculated for demographic characteristics, treatment patterns, and comorbidity.

RESULTS

The prevalence of LP was 95.9 and the incidence was 20.1 per 100,000 individuals in 2018, corresponding to 79,605 prevalent LP cases in Germany. The first LP diagnosis was generally documented by a dermatologist or a primary care physician. Three-quarters of the incident and half of the prevalent patients received topical therapy, mostly without further systemic therapy. Comorbidity in LP patients was consistent with previously known associations.

CONCLUSIONS

Available treatment options remain limited, underscoring the unmet need for safe and efficacious systemic treatment modalities. Lichen planus is frequently accompanied by clinically relevant systemic comorbidity. Taken together, these observations may improve our understanding of the burden of this disease and increase diagnostic awareness among clinicians.

Efficacy and Safety of Oral Methotrexate versus Oral Mini Pulse Betamethasone Therapy in the Treatment of Lichen Planus: A Comparative Study

BACKGROUND

Lichen planus (LP) is a chronic inflammatory mucocutaneous disease. Systemic corticosteroids are the treatment of choice for generalized LP but their use is limited due to side effects. Oral mini pulse (OMP) therapy represents good alternative. Also, Methotrexate (MTX) can be used as alternative and safe modality in LP.

OBJECTIVES

To compare the efficacy and safety of oral MTX versus OMP betamethasone in treatment of different types of LP.

PATIENTS AND METHOD

The study included 40 patients presenting with LP who were randomly divided into two groups. Group A for oral MTX 7.5 mg weekly & group B for OMP betamethasone 3 mg weekly for maximum 12 weeks. Basic laboratory investigations were done to both groups. Follow up investigations were done at 2nd, 4th, 8th and 12th week. Percentage of improvement in each patient was calculated on a scale according to appearance of new lesions, degree of pruritus/pain, subsidence of cutaneous lesions and clearance of oral lesion.

RESULTS

In MTX group, 55% of patients showed excellent improvement, 25% showed good improvement and 20% showed partial improvement. In OMP group, 85% of patients showed excellent improvement, 10% showed good improvement and 5% showed partial improvement. The reported clinical and laboratory adverse effects were tolerable and didn't lead to discontinuation of treatment.

CONCLUSION

OMP betamethasone and low dose MTX may be considered effective and safe lines of treatment for different types of LP and may represent good and safe alternative options for conventional daily corticosteroid therapy.

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.

Pediatric lichen planus: a systematic review of 985 published cases

BACKGROUND

Lichen planus (LP) is a chronic inflammatory disorder usually occurring in middle-aged adults. Data are scarce in the pediatric population.

OBJECTIVE

To describe the patients' characteristics, clinical presentation, and management of pediatric LP.

METHODS

A systematic literature review of pediatric LP was performed in the Medline and Cochrane databases up to February 1, 2020. Demographic and clinical data were extracted for analysis, in addition to laboratory and histology findings, treatments used, and response to treatment. LP pemphigoides (LPP) was further pooled for a subcategory analysis.

RESULTS

One hundred and sixty-four articles were included representing 985 patients. The most common country of origin was India. The most common clinical signs were flat-topped papules (51%); the linear variant was present in 9%. Oral involvement was present in 22%. The most commonly used treatment was topical corticosteroids followed by systemic corticosteroids. The mean duration of treatment was 124.4 days. LPP patients had a short disease duration before diagnosis (4.1 months, P < 0.001) and failed previous treatment more frequently (P < 0.001). Systemic corticosteroids were more often prescribed in this subgroup (75%, P < 0.001) with more recurrence after treatment (31%, P = 0.048).

LIMITATIONS

Lack of randomized controlled studies, in addition to publication bias.

CONCLUSION

In children, LP had a wide polymorphous clinical presentation, and the reported cases were mostly from India. The linear variant was more common and the oral mucosa was less affected in children. LPP, a rare subtype in children, was treated with systemic corticosteroids and recurred more frequently.

Oxidative Stress in Cutaneous Lichen Planus-A Narrative Review

Lichen planus (LP) is a chronic, immune-mediated inflammatory skin condition that mainly affects the skin (cutaneous LP, CLP) and oral mucosa (oral LP, OLP). However, the mechanisms involved in the pathogenesis of the disease are not fully elucidated. Over time, several theories that could explain the appearance of LP lesions have been postulated. The key players in LP pathogenesis are the inflammatory infiltrate consisting of T cells and the proinflammatory cytokines. The cytokines stimulate the production of reactive oxygen species that induce cell apoptosis, a defining element encountered in LP. The lead inquiry triggered by this revolves around the role of oxidative stress in LP development. There are currently numerous studies showing the involvement of oxidative stress in OLP, but in terms of CLP, data are scarce. In this review, we analyze for the first time the currently existing studies on oxidative stress in CLP and summarize the results in order to assess the role of oxidative stress in skin lesions offering a fresher updated perspective.

Successful systemic treatment outcomes of lichen planus: A single-center retrospective review

Lichen planus (LP) affects up to 4% of adults and can cause significant distress and morbidity, especially to those with persistent disease. As many as 20% of patients with LP may exhibit widespread or recalcitrant disease necessitating systemic treatment options. We sought to evaluate the effectiveness of systemic treatments for severe and recalcitrant LP not responsive to topical corticosteroids or calcineurin inhibitors. Over a 10-year period, 374 patients with cutaneous and mucosal LP were evaluated at a major regional tertiary medical center; 94 qualified for inclusion in the study. In all, 26 (28%) patients achieved remission, 52 (55%) experienced stable disease control, and 16 (17%) failed all attempted treatments. Among medications most trialed, intramuscular triamcinolone (IM TAC), hydroxychloroquine, and methotrexate were most successful with 79%, 61%, and 42% respective response rates. In contrast, oral corticosteroids and dapsone were less frequently successful at rates of 24% and 20%. IM TAC represented the highest level of treatment success and was statistically significant compared to other systemic treatments (P < .01). Among adjuvant therapies, intralesional triamcinolone (IL TAC) demonstrated higher success (71%) than oral corticosteroids (29%). Based on this multi-year evaluation, we recommend that clinicians consider IM TAC as a first-line systemic option for severe or refractory LP, with hydroxychloroquine as the steroid-sparing treatment of choice. For patients requiring adjuvant therapy, IL TAC should be considered to hasten response and symptom relief. Patients with severe or widespread disease may benefit from earlier initiation of systemic therapy to prevent significant morbidity and impact on daily function.