Nail Lichen Planus: Successful Treatment with Etanercept

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.

Successful treatment of nail lichen planus with tofacitinib: a case report and review of the literature

Nail lichen planus (NLP) is a chronic inflammatory disease of unknown etiology and has been recognized as a nail potentially critical disorder, which can be severe and rapidly worsen with irreversible scarring. Currently, the treatment options are limited based on disease progression. High-potency topical or intralesional corticosteroids are commonly considered first-line therapeutic options; however, these therapies are unsuitable for all patients with NLP, especially those with extensive lesions. As a potential therapeutic target for inflammatory skin diseases, Janus kinase (JAK) inhibitors can suppress both type-1 and type-2 cytokines, thereby reducing the immune response and resultant inflammation. Recent studies have suggested benefit in cutaneous lichen planus and lichen planopilaris with oral JAK inhibitors. Here, we report a case of severe NLP that exhibited a favorable response to tofacitinib treatment. A 41-year-old woman presented to our clinic with a 2-year history of nail dystrophy of all fingers of both hands. The NLP was finally confirmed by histopathology and the above clinical features. After the informed consent signature, tofacitinib monotherapy, 5 mg twice a day, was then begun, and after 6 months, the appearance of her nails had a significant improvement.

Nail lichen planus treatment safety

AREAS COVERED

Topical therapies for nail lichen planus (clobetasol propionate, topical tacrolimus, bath-PUVA), intralesional treatment (triamcinolone), and systemic treatment (corticosteroids, retinoids, small molecule inhibitors (jak/stat inhibitors)), TNF-alpha inhibitors (etanercept), systemic immunomodulators (oral calcineurin inhibitors, mycophenolate mophetil), and antimalarials (chloroquine), each with unique safety profiles and considerations. Herein, we discuss common and uncommon adverse events, as well as utilization for special populations, including pregnant and pediatric patients.

Expression and Significance of TNF-α and NF-κB/p65 in Cutaneous Lichen Planus

Purpose

The purpose of this study was to explore the expression of TNF-α and NF-κB/p65 in Lichen planus skin lesions and their correlation with the pathogenesis of Lichen planus.

Patients and Methods

The case group consisted of 30 individuals diagnosed with LP based on clinical and histopathologic examination. The control group consisted of 10 individuals from an Orthopedic Department with normal skin. TNF-α and NF-κB/p65 expression in skin tissue samples was detected by immunohistochemistry.

Results

The immunohistochemical results showed that TNF-α and NF-κB/p65 expression levels were significantly higher in LP skin lesions than normal skin tissues (P ≤ 0.05). Positive TNF-α staining mainly occurred in the cytoplasm of keratinocytes of the stratum granulosum, stratum spinosum, and stratum basale in the epidermis and lymphocytes in the superficial dermis. Positive NF-κB/p65 staining mainly occurred in the nucleus and cytoplasm of keratinocytes of the stratum spinosum and stratum basale in the epidermis and lymphocytes in the superficial dermis.

Conclusion

TNF-α and NF-κB/p65 are overexpressed in cutaneous LP. The two are positively correlated in LP, suggesting that they both play essential roles in the pathogenesis of LP.

Nail lichen planus: A review of clinical presentation, diagnosis and therapy

Lichen planus is a multifaceted disease of complex etiopathogenesis. Nails are involved in up to 10% of patients with lichen planus. Although most cases are mild, serious consequences may occur due to rapid progression of the disease, the high risk of scarring, and the resulting irreversible damage to the nail structure. Permanent damage of at least one nail occurs in approximately 4-12% of patients with nail lichen planus. In this narrative review, we emphasize the pathophysiology of nail lichen planus, the emergent nature of the disease, and the spectrum of different clinical manifestations. Diagnosis of nail disease in general, and of nail lichen planus in particular, is rapidly evolving. This review provides a comprehensive account of the non-invasive and invasive diagnostic techniques and treatment options reported in the literature, with emphasis on the efficacy and safety of the drugs used, the associated evidence, and the factors to be taken into account in planning and providing adequate treatment. The role of aesthetic and camouflage options is also summarized.

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.

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.

Biologics in Dermatology: Off-Label Indications

Skin and subcutaneous diseases affect millions of people worldwide, causing significant morbidity. Biologics are becoming increasingly useful for the treatment of many skin diseases, particularly as alternatives for patients who have failed to tolerate or respond to conventional systemic therapies. Biological therapies provide a targeted approach to treatment through interaction with specific components of the underlying immune and inflammatory disease processes. Advances in the understanding of disease pathophysiology for inflammatory skin diseases and in drug development have ushered in biologic therapies in dermatology. Biologic therapies are molecules that target specific proteins implicated in immune-mediated disease. This review article highlights the increasing evidence base for biologics in dermatology for off-label use.

Isolated nail lichen planus: An expert consensus on treatment of the classical form

Lichen planus is a benign inflammatory disorder of unknown etiology that may affect the skin, mucosae, scalp, and nails. When the nails are affected, it may lead to permanent destruction with severe functional and psychosocial consequences. Therefore, prompt diagnosis and early treatment are essential, even in mild cases. There are currently no guidelines for the management of nail lichen planus and the published literature on treatment is limited. The aim of this review is to provide practical management recommendations for the classical form of nail lichen planus, especially when restricted to the nails. Topical treatment has poor short-term efficacy and may cause long-term side effects. Instead, intralesional and intramuscular triamcinolone acetonide should be considered first-line therapies. Oral retinoids are second-line choices, and immunosuppressive agents may also be considered.

Successful treatment of psoriatic arthritis and comorbid annular atrophic lichen planus with etanercept

Psoriasis vulgaris and lichen planus are distinct T-cell-driven inflammatory skin diseases. Both present in a variety of clinical subtypes. Mucosal or nail involvement may be present. Here, we report the rare concomitant clinical presentation of psoriatic arthritis and annular atrophic lichen planus on the trunk of a 52-year-old male patient. Treatment with sulfasalazine failed to control inflammatory activity; methotrexate and leflunomide were ceased due to side-effects. After confirmation of both diagnoses, we initiated a tumor necrosis factor (TNF)-α-directed therapy with the fusion protein etanercept resulting in significant improvement of both conditions. This case report aims to highlight the rare colocalization of psoriasis and lichen planus, the rare entity of annular atrophic lichen planus, and to discuss a possible beneficial impact of certain TNF-α inhibitors on subtypes of lichen planus.

Therapeutics for Adult Nail Psoriasis and Nail Lichen Planus: A Guide for Clinicians

Nail psoriasis (NP) and nail lichen planus (NLP) can be limiting, stigmatizing and difficult to treat. Dermatologists commonly treat psoriasis and lichen planus but when associated onychodystrophy is present or is an isolated finding, some develop apprehension. The goal of this review is to develop therapeutic ladders to be used as a guide for the management of NP and NLP in everyday clinical practice. Evidence-based therapies for NP are robust and range from topical treatments to conventional systemic therapies (i.e., methotrexate, cyclosporine), new oral agents (i.e., apremilast and tofacitinib), and biologics. The literature for treatment of NLP is severely limited, with therapy mainly consisting of topical, intralesional, or systemic corticosteroids or methotrexate.

Coexistence of nail lichen planus and lichen planus pigmentosus

We describe a fifty-six-year old, Afro-descendent female patient showing dystrophy of her twenty nails and hyperchromic, asymptomatic macule on her face. Histopathological examination of the macule showed vacuolization of the basal layer, melanophages in the superficial dermis and lymphoplasmocytic inflammatory infiltrate. Nail biopsy revealed orthokeratotic hyperkeratosis and lichenoid inflammatory infiltrate. Lichen planus pigmentosus is an uncommon variety of lichen planus. It is characterized by typical hyperpigmented macules on the face and neck. Nail changes might be present in 10% of lichen planus cases, but no associations with lichen planus pigmentosus have been described. We report a case of lichen planus in twenty nails associated with lichen planus pigmentosus on the patient's face.

Lichen planus and dyslipidemia: a systematic review and meta-analysis of observational studies

BACKGROUND

Lichen planus (LP) is a chronic inflammatory disease that has been shown to be positively associated with dyslipidemia. However, the magnitude and types of the underlying lipid abnormalities have not been investigated. This study aims to conduct a systematic review and meta-analysis to investigate the qualitative and quantitative association between LP and dyslipidemia.

METHODS

A systematic search of studies published from inception to April 1, 2015, was conducted using MEDLINE, EMBASE, Web of Science, and Cochrane library databases. Meta-analyses of observational studies with both categorical and continuous outcome were performed. DerSimonian and Lard random effects models were utilized to calculate the pooled odds ratio and weighted mean difference (WMD). Publication bias was evaluated by funnel plot and Egger's test.

RESULTS

Seven studies with 5242 subjects were included in this meta-analysis. Patients with LP were significantly more likely to have dyslipidemia, with a pooled odds ratio of 1.74 (95% confidence interval [CI]: 1.19-2.54, P = 0.004). LP was associated with higher levels of triglycerides (WMD 83.37 mg/dl, 95% CI 0.62-166.12, P = 0.048), low-density lipoprotein (18.75 mg/dl, 95% CI -17.21 to 54.72, P = 0.307), total cholesterol (19.22 mg/dl, 95% CI -8.80 to 47.25, P = 0.179), and lower levels of high-density lipoprotein cholesterol (-8.96 mg/dl, 95% CI -21.22 to 3.30, P = 0.152).

CONCLUSIONS

Despite considerable heterogeneity, this study demonstrated that LP was significantly associated with an increased risk of dyslipidemia and higher triglyceride levels. For patients presenting with LP, physicians should be cognizant of this association and consider screening them for dyslipidemia.

Individualizing treatment and choice of medication in lichen planus: a step by step approach

Although lichen planus is one of the most common dermatological entities, very few reviews on its management exist in the literature. Standard therapeutic approaches include various topical treatments (including topical corticosteroids, calcineurin inhibitors, vitamin D analogs) and phototherapy modalities, as well as systemic corticosteroids and systemic retinoids. While localized skin lesions are easily managed with standard modalities, generalized forms and in particular involvement of hair follicles, nails and mucosa, as well as eyes are often challenging. This review proposes an evidence-based and differential therapeutic regime, taking into account many new emerging systemic therapies to help clinicians optimize treatment according to the type, extent and severity of the disease. An individual therapeutic ladder has been developed for each location, starting with standard modalities and ranking alternative systemic treatments (mainly methotrexate and hydroxychloroquine, as well as cyclosporine, azathioprine and mycophenolate mofetil) according to efficacy, evidence level and side-effect profile.

Oral, esophageal and cutaneous lichen ruber planus controlled with alitretinoin: case report and review of the literature

BACKGROUND

Therapy-resistant lichen planus (LP) can be a challenging condition for dermatologists. There are some case reports about successful treatments with alitretinoin of cutaneous and oral, but not of esophageal LP.

OBJECTIVE

We present the unique case of a patient with cutaneous, oral and esophageal LP which was refractory to classical treatment options (topical clobetasol propionate and pimecrolimus, intramuscular triamcinolone acetonide); because of systemic side effects the patient did not tolerate systemic acitretin dosed up to 25 mg daily.

METHODS

Oral alitretinoin was used at a dose of 30 mg daily.

RESULTS

Both oral and skin changes as well as dysphagia completely resolved within 4 weeks without any severe side effects and the drug was used for 6 months. No papules, intraoral striae or dysphagia recurred during the 6 months of treatment. After 4 months the patient relapsed with mucosal patches so that a second cycle was initiated for 6 months where oral LP lesions resolved after 4 weeks also (with sporadic mild headache).

CONCLUSION

Further studies are needed to better understand the impact of alitretinoin in LP. Our observation suggests alitretinoin as a new, well-tolerated treatment option for esophageal LP after failed response to conventional treatments.