Early intervention leads consensus recommendations for lichen planus
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Early diagnosis and intervention are critical in managing lichen planus, a benign inflammatory disorder that may affect the skin, mucosae, scalp and nails, according to the authors of a set of consensus recommendations.
“There are currently no guidelines for the management of nail lichen planus, and the published literature on treatment is limited,” Matilde Iorizzo, MD PhD, who has a private dermatology practice in Bellinzona, Switzerland, told Healio. “The aim of this paper is then to provide practical management recommendations for the classical form of nail lichen planus, especially when restricted to the nails.”
Iorizzo and colleagues wrote that lichen planus remains of unknown etiology. While the condition is benign, when nails are implicated, permanent destruction may occur. “Nail lichen planus may cause significant discomfort and permanent nail destruction, so prompt treatment is essential,” Iorizzo said.
The group recommended intralesional triamcinolone acetonide as the first-line intervention. “According to the authors’ experience, topical treatment has poor short-term efficacy and may cause long-term side effects,” Iorizzo said.
To manage injection site pain associated with intralesional triamcinolone acetonide, the experts suggested ethyl chloride spray, “talkesthesia” and the concomitant use of vibrating devices. While data are limited for the optimal dose of intralesional triamcinolone acetonide, a concentration of 2.5 mg/mL, 5 mg/mL or 10 mg/mL, according to disease severity, may be used. Clinicians may repeat injections every 4 to 5 weeks for a minimum of 4 to 6 months to achieve results, according to the statement.
For clinicians looking for an adjunct to intralesional triamcinolone, intramuscular administration may be considered. A dose of 0.5 mg/kg to 1 mg/kg monthly for a minimum of 3 to 6 months is recommended in pediatric and adult patients. During the active therapy period, a dose of 1 mg/kg per month is recommended.
Looking beyond triamcinolone, systemic corticosteroids, retinoids and immunosuppressive agents may also be considered but with caution, according to the authors. They discouraged steroid use due to the adverse event profile.
“Oral retinoids are instead second-line choices and work better in mild to moderate cases,” Iorizzo said. “Low dosages are mandatory.”
Acitretin at a dose of 0.2 mg/kg to 0.3 mg/kg per day and alitretinoin at 30 mg per day are attractive options for patients with contraindications to steroids. However, these therapies may be useful in cutaneous and oral lichen planus, but their efficacy in nail lichen planus remains questionable.
“Nail lichen planus may cause significant discomfort to patients due to its dystrophic nature,” Iorizzo said. “Early treatment is always recommended, and the wait-and-see approach is generally not advisable due to the unpredictable course of this disease.” – by Rob Volansky
Disclosures: The authors report no relevant financial disclosures.
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