Review of Nail Lichen Planus: Epidemiology, Pathogenesis, Diagnosis, and Treatment

Ultrasound Features of Nail Lichen Planus

OBJECTIVES

To describe the ultrasonographic features of nail lichen planus (NLP), which, so far, have not been reported in the literature.

METHODS

A retrospective single-center study of NLP patients' color Doppler ultrasound examinations was performed between March 2014 and January 2023. Inclusion criteria were patients ≥15 years with a confirmed clinical diagnosis of NLP in sequential order. Exclusion criteria included concomitant systemic or local cutaneous or nail diseases and systemic or local nail treatments before the ultrasound examination. The ultrasound protocol included the examination of all fingernails or toenails following the reported protocol for dermatologic ultrasound examinations at high and ultra-high frequencies. Patient demographics and ultrasound features of the nail bed, periungual region, nail plate, and regional vascularity were registered and analyzed statistically.

RESULTS

A total of 36 patients met the criteria. All cases presented thickened and decreased echogenicity of the nail bed. A hypoechoic halo surrounding the origin of the nail plate was present in 78% of cases. Exactly 58% of patients presented decreased echogenicity of the proximal periungual dermis, and 86% showed thickening of the periungual dermis. Hypervascularity of the nail bed was seen in 94% of cases. The mean maximum thickness of vessels, the peak systolic velocity of the arterial vessels, and other blood flow findings are provided.

CONCLUSION

Ultrasonography can support the diagnosis of NLP, which benefits the non-invasive discrimination of nail conditions and can avoid the potential permanent scars derived from nail biopsies. Furthermore, ultrasound may be a powerful tool to monitor this disease's treatment.

Nail psoriasis and nail lichen planus: Updates on diagnosis and management

BACKGROUND

Inflammatory diseases of the nail, including nail psoriasis and nail lichen planus, are associated with significant disease burden and have a negative impact on quality of life. Diagnosis is often delayed, especially when patients present without cutaneous findings. Therefore, recognizing clinical signs and symptoms of inflammatory nail diseases, and initiating timely and appropriate treatment, is of utmost importance.

OBJECTIVE

We review recent studies on diagnostic techniques, discuss severity grading and scoring systems, and describe consensus treatment recommendations for nail psoriasis and nail lichen planus.

METHODS

An updated literature review was performed using the PubMed database on studies assessing diagnostic techniques or treatment modalities for nail psoriasis and nail lichen planus.

RESULTS

Recent studies on diagnostic techniques for inflammatory nail disease have focused on use of dermoscopy, capillaroscopy, and ultrasound modalities. Treatment of these conditions is dichotomized into involvement of few (≤3) or many (>3) nails. Recent psoriatic therapeutics studied for nail outcomes include brodalumab, tildrakizumab, risankizumab, deucravacitinib, and bimekizumab, while emerging treatments for nail lichen planus include JAK inhibitors and intralesional platelet rich plasma injections.

CONCLUSIONS

We emphasize the need for increased awareness and expanded management strategies for inflammatory nail diseases to improve patient outcomes.

Oral Lichen Planus: An Update on Diagnosis and Management

Oral lichen planus (OLP) is a chronic inflammatory disease whose pathogenesis involves a T-cell mediated, epithelium-directed inflammation in response to unknown antigen(s). The disease evolves by intermittent flares and displays polymorphous clinical features (reticular, erosive, atrophic, plaque, papular, bullous, etc.). When present, symptoms vary depending on the clinical form and range from discomfort to severe pain. Topical superpotent corticosteroids constitute the first-line treatment of symptomatic flares, whereas a wide range of second/third-line treatments are available among topical calcineurin inhibitors, systemic corticosteroids, systemic retinoids, topical/systemic immunomodulators, etc. Follow-up of patients is necessary to detect transformation into squamous cell carcinoma, occurring in approximately 1% of patients.

Inverse Lichen Planus Associated With Nail Dystrophy

Lichen planus is a chronic inflammatory disorder affecting skin and mucosal surfaces. There are multiple variants of lichen planus described in the literature. We report a case of inverse lichen planus in a healthy 50-year-old male who presented to our dermatology clinic with multiple violaceous to hyperpigmented patches affecting both axillae and groin for three months. A skin biopsy confirmed the diagnosis of lichen planus. The patient subsequently developed nail dystrophy affecting his fingernails consistent with nail lichen planus. Early recognition and treatment of nail lichen planus is important to prevent irreversible scarring.

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.

Comprehensive Insight into Lichen Planus Immunopathogenesis

Lichen planus is a chronic disease affecting the skin, appendages, and mucous membranes. A cutaneous lichen planus is a rare disease occurring in less than 1% of the general population, while oral illness is up to five times more prevalent; still, both forms equally impair the patient's quality of life. The etiology of lichen planus is not entirely understood. Yet, immune-mediated mechanisms have been recognized since environmental factors such as hepatitis virus infection, mechanical trauma, psychological stress, or microbiome changes can trigger the disease in genetically susceptible individuals. According to current understanding, lichen planus immunopathogenesis is caused by cell-mediated cytotoxicity, particularly cytotoxic T lymphocytes, whose activity is further influenced by Th1 and IL-23/Th-17 axis. However, other immunocytes and inflammatory pathways complement these mechanisms. This paper presents a comprehensive insight into the actual knowledge about lichen planus, with the causal genetic and environmental factors being discussed, the immunopathogenesis described, and the principal effectors of its inflammatory circuits identified.

Bullous Lichen Planus of the Nails: A Case Report and Review of the Literature

Lichen planus is a chronic inflammatory disorder that may affect the skin, nails, and/or oral mucosa. Bullous lichen planus is a rare variant of lichen planus, which is even less common in the nails. We present a case of nail bullous lichen planus, in a 48-year-old male presenting with a 10-month history of onychodystrophy of all ten fingernails. A longitudinal excision of the left thumbnail was performed, with histopathology consistent with lichen planus with focal transition to bullous lichen planus. He was treated with intralesional triamcinolone injections to the fingernails monthly, with improvements noted after three treatments. Our patient's nail bullous lichen planus manifested with longitudinal ridging, white-yellow discoloration, onycholysis, subungual hyperkeratosis, and v-shaped nicking. Histopathological findings included classical lichen planus changes, as well as formation of subepidermal bullae, colloid bodies, and extensive inflammatory infiltrate. Increased awareness and high index of suspicion for this condition are necessary, given the often late diagnosis reported in previously published cases.

Unilateral lichen planus with Blaschko line distribution: A case report

BACKGROUND

Lichen planus (LP) with distribution of lesions along Blaschko’s lines is a rare entity, accounting for 0.24%-0.62% of all patients. Unilateral distribution of lesions in arm, leg, trunk, and waist is even less common. Approximately 10% of patients with LP manifest nail lesions.

CASE SUMMARY

A 20-year-old woman presented to our department with polygonal, purpuric, flat-topped papules over the right arm, right leg, and right side of trunk and waist for the last 5 mo. The patient initially developed nail deformation in the left middle finger with no obvious cause, followed by development of blue-purple and red maculopapular rash with pruritus. During the disease course, the skin lesions aggravated and spread to several segments due to scratching. The lesions showed unilateral distribution along the Blaschko’s lines. The diagnosis of LP along Blaschko’s lines was established based on dermoscopy and skin biopsy. Her cutaneous lesions considerably improved after 4-wk treatment with intramuscular glucocorticoid, oral acitretin, topical glucocorticoid, and retinoids.

CONCLUSION

Cases of LP involving multiple segments of the body along the Blaschko’s lines with nail damage are rare.

Description of the most severe signs in nail lichen planus: a strategy to contribute to the diagnosis of the severe stage

BACKGROUND

Severe nail lichen planus (NLP) does not respond well to treatment and is often poorly considered and described in detail.

OBJECTIVE

We sought to describe the characteristics of severe NLP.

METHODS

A retrospective data analysis was performed, including the photographic records of the most compromised nails of patients with NLP over 18 years old, who consulted between 2009 and 2019 at the Instituto de Dermatologia Professor Rubem David Azulay in Rio de Janeiro, Brazil. Descriptive and statistical analysis using Fisher's exact test was performed to verify the hypothesis of independence between characteristics (P < 0.05).

RESULTS

A total of 102 patients were included. Anonychia was associated with severe thinning of the nail plate, retraction of the nail bed or nail plate, residual nail plate, loss of proximal nail fold limits, and onychoatrophy. Dorsal pterygium was associated with loss of proximal nail fold limits, onychoatrophy, and distal splitting greater than 50%.

CONCLUSION

We provide descriptions of the most severe signs in order to facilitate the clinical diagnosis when a biopsy is not feasible and suggest an update of current NLP classifications.

Multiple Clinical Manifestations of Lichenoid Spectrum: A Patient with Frontal Fibrosing Alopecia, Lichen Planus Pigmentosus, and Nail Lichen Planus

<b><i>Introduction:</i></b> Frontal fibrosing alopecia (FFA) is characterized by irreversible, symmetrical band-like hair loss in the frontotemporal region. Lichen planus pigmentosus (LPP) is a variant of lichen planus (LP) that presents with hyperpigmented macules and patches predominantly in sun-exposed areas. Nail LP is a subtype of LP that can be present alone or with other forms of LP. <b><i>Case Report:</i></b> We report a rare case of a 59-year-old woman presenting with symmetrical, gray-brown, hyperpigmented lesions on her neck and face, band-like alopecia in the frontotemporal region, severe onycholysis in two fingernails, and prominent longitudinal ridging in all fingernails. Clinical, dermoscopic, and histological findings established a diagnosis of FFA associated with LPP and nail LP was established. <b><i>Discussion/Conclusion:</i></b> In recent years, it has been established that FFA can be associated with LPP and it is thought to be a variant of lichen planopilaris. Nail involvement is rarely reported in FFA or LPP. To our knowledge, the presence of the three conditions in the same patient has not been previously reported. Although rare we would like to emphasize the importance of a careful examination of the nails in patients with FFA and/or LPP to prevent irreversible nail changes.

Lichen Planus Activity and Damage Index (LiPADI)–Creation of the Questionnaire

Introduction: Lichen planus (LP) is a chronic autoimmune disease that affects skin, oral and genital mucosa, and other sites. Basic difficulties in assessment of LP are multitude of disease forms and diverse locations of lesions. Moreover, there is lack of objective and consolidated tool for assessment of disease severity and LP progression. Objective: The aim of the study was to develop a valid evaluation tool of LP severity, which will enable disease assessment in a repetitive way. Materials and methods: A combined tool called Lichen Planus Activity and Damage Index (LiPADI) was developed to assess the severity of LP skin, mucosal, and nail lesions as well as hair loss/scaring alopecia to provide an integrative scoring for LP activity and damage caused by the disease. Skin lesions were assessed in nine locations: scalp, face, chest, abdomen, back and buttocks, arms, hands, legs, and feet. The assessment of lesion activity included erythema, hypertrophy, and scaling, while the damage was reflected by the assessment of hyperpigmentation and scaring/atrophy. In addition, mucosal lesions, nail abnormalities, hair loss, and scarring alopecia were evaluated as well. LiPADI scoring was compared with quality of life assessed with the Dermatology Life Quality Index, EQ-5D calculator, pain and pruritus intensity assessed with the Numerical Rating Scale as well as with the patient and physician global assessment. Results: Our results show that LiPADI well reflects the LP patient’s clinical condition. The obtained results were in line with other indicators assessed. In addition, it was possible to evaluate patients with various forms and locations of LP, what indicates its versatility. Conclusions: LiPADI seems to be a useful tool for measurement the severity of the LP and its progress over time, which could help to monitor the effectiveness of the patients’ treatment.