Successful treatment of lichen planus with low-molecular-weight heparin: a case series of seven patients

Therapeutic Potential of Enoxaparin in Lichen Planus: Exploring Reasons for Inconsistent Reports

Lichen planus (LP) is an uncommon mucocutaneous inflammatory condition, that is immunologically mediated, typically pruritic and often recurs. The currently advocated therapies are either not highly effective or associated with severe side effects. Enoxaparin, a widely used anticoagulant, is composed of both anticoagulant and non-anticoagulant fragments. Enoxaparin is reported to have anti-inflammatory properties and it was found to be effective in LP. However, the results from clinical studies have varied substantially and, therefore, the clinical role of enoxaparin in LP remains uncertain. This review focuses on potential reasons for the reported inconsistent outcomes, as well as proposing solutions; these include identifying batch-to-batch inconsistency in the composition of enoxaparin. The potential therapeutic value of enoxaparin in LP must be explored using well-designed clinical trials, combined with experimental studies that focus on identifying the anti-inflammatory fragments of enoxaparin and elucidating the mechanism of action of these non-anticoagulant fragments.

Primary cicatricial alopecia: Lymphocytic primary cicatricial alopecias, including chronic cutaneous lupus erythematosus, lichen planopilaris, frontal fibrosing alopecia, and Graham-Little syndrome

Both primary and secondary forms of cicatricial alopecia have been described. The hair follicles are the specific target of inflammation in primary cicatricial alopecias. Hair follicles are destroyed randomly with surrounding structures in secondary cicatricial alopecia. This 2-part continuing medical education article will review primary cicatricial alopecias according to the working classification suggested by the North American Hair Research Society. In this classification, the different entities are classified into 3 different groups according to their prominent inflammatory infiltrate (ie, lymphocytic, neutrophilic, and mixed). Part I discusses the following lymphocytic primary cicatricial alopecias: chronic cutaneous lupus erythematosus, lichen planopilaris, frontal fibrosing alopecia, and Graham-Little syndrome.

Low-Molecular-Weight Heparins as Immunomodulators in Dermatology Practice

Low-molecular-weight heparins (LMWHs) have some effects on cell proliferation and inflammation beyond mere anticoagulation. They have been tried on treatment of a few dermatological disorders such as lichen planus, skin wound healing, recurrent aphtous stomatitis, chronic urticaria, and contact hypersensitivity. LMWHs are generally well-tolerated drugs, rarely can lead to severe reactions. In this article, we will review the novel indications of LMWHs in dermatology practice and common skin reactions associated with their use.

Opposing effects of low molecular weight heparins on the release of inflammatory cytokines from peripheral blood mononuclear cells of asthmatics

Background

T-cell-mediated inflammatory cytokines, such as interleukin (IL)-4, IL-5, IL-13 and tumor necrosis factor-alpha (TNF-α), play an important role in the initiation and progression of inflammatory airways diseases. Low-molecular-weight heparins (LMWHs), widely used anticoagulants, possess anti-inflammatory properties making them potential treatment options for inflammatory diseases, including asthma. In the current study, we investigated the modulating effects of two LMWHs (enoxaparin and dalteparin) on the release of cytokines from stimulated peripheral blood mononuclear cells (PBMCs) of asthmatic subjects to identify the specific components responsible for the effects.

Methods

PBMCs from asthmatic subjects (consist of ~75% of T-cells) were isolated from blood taken from ten asthmatic subjects. The PBMCs were pre-treated in the presence or absence of different concentrations of LMWHs, and were then stimulated by phytohaemagglutinin for the release of IL-4, IL-5, IL-13 and TNF-α. LMWHs were completely or selectively desulfated and their anticoagulant effect, as well as the ability to modulate cytokine release, was determined. LMWHs were chromatographically fractionated and each fraction was tested for molecular weight determination along with an assessment of anticoagulant potency and effect on cytokine release.

Results

Enoxaparin inhibited cytokine release by more than 48%, whereas dalteparin increased their release by more than 25%. The observed anti-inflammatory effects of enoxaparin were independent of their anticoagulant activities. Smaller fractions, in particular dp4 (four saccharide units), were responsible for the inhibitory effect of enoxaparin. Whereas, the larger fractions, in particular dp22 (twenty two saccharide units), were associated with the stimulatory effect of dalteparin.

Conclusion

Enoxaparin and dalteparin demonstrated opposing effects on inflammatory markers. These observed effects could be due to the presence of structurally different components in the two LMWHs arising from different methods of depolymerisation. This study provides a platform for further studies investigating the usefulness of enoxaparin in various inflammatory diseases.

Effect of enoxaparin and onion extract on human skin fibroblast cell line - therapeutic implications for the treatment of keloids

CONTEXT

Keloids and hypertrophic scars are hyperproliferative skin disorders resulting in abnormal wound healing. In the prevention and treatment of keloids and hypertrophic scars, ointments containing heparin and onion extract are very popular. Their therapeutic effects, however, are still controversial and the mechanism of action is not fully understood.

OBJECTIVE

The aim of this study was to assess the effect of enoxaparin and dry onion extract on proliferation, apoptosis and β1 integrin expression in human fibroblasts.

MATERIALS AND METHODS

Fibroblast human cell lines (46 BR.1 N) were treated for 48 h with various concentrations of enoxaparin sodium (20, 100, 500 µg/mL) and/or onion [Allium cepa L. (Alliaceae)] extract (50, 250, 1000 µg/mL). The cell proliferation was evaluated by [(3)H]-thymidine incorporation assay. Furthermore, the expression of β1 integrin and apoptosis was determined by flow cytometry.

RESULTS AND DISCUSSION

The results demonstrate that enoxaparin and onion extract inhibited the proliferation of human fibroblasts. Almost complete inhibition of cell proliferation was achieved by enoxaparin in 500 µg/mL concentration (91.5% reduction). The onion extract at a concentration of 250 µg/mL also strongly inhibited the proliferation of cells (50.8% reduction). Depending on concentration, enoxaparin and onion extract induced apoptosis (500 and 1000 µg/mL, respectively) and, depending on concentration, downregulated the expression of β1 integrin on human fibroblasts.

CONCLUSION

This work points at possible mechanism of action of enoxaparin and onion extract, when administered in the treatment of patients with keloids and hypertrophic scars.

Comparison of therapeutic effect of low-dose low-molecular-weight heparin (enoxaparin) vs. oral prednisone in treatment of patients with lichen planus; A clinical trial

BACKGROUND

The aim of this study was to evaluate and compare the therapeutic efficacy of subcutaneous enoxaparin versus oral prednisone (as a standard treatment) in patients with disseminated lichen planus.

MATERIALS AND METHODS

In this parallel randomized clinical trial study, overall 48 patients completed the study. 25 patients were treated with subcutaneous enoxaparin 5 mg weekly and 23 patients with 0.5 mg/kg prednisone orally daily until complete remission or a maximum of 8 weeks. The results of itching severity, extent of active lesions and drug side effects were compared. In remission, patients were followed for 6 months for recurrent lesions.

RESULTS

In enoxaparin group, 8 patients (32%) had complete remission and 10 patients (40%) had partial improvement. In the oral prednisone group, 16 patients (69.6%) had complete remission and 6 patients (26.1%) had partial improvement (P = 0.005). Average size of active lesions in both groups decreased significantly after treatment, but analysis of covariance showed that the mean lesion size after treatment in the oral prednisone group was significantly lower than the enoxaparin group (P = 0.005). The relapse rate from improved patients in the enoxaparin group was 6 (33%) and in oral prednisone group was 9 (40.9%, P = 0.083). In the enoxaparin group no serious complications was seen. But 22% in the oral prednisone group show side effect, the most common complications were dyspepsia.

CONCLUSION

Low dose enoxaparin on lichen Planus have therapeutic effect and is important for the least side effects but not as much as oral prednisone. But it could be accepted as an alternative treatment.

Erosive diseases of the vulva

Vesicobullous and inflammatory diseases produce vulvar erosions that may exhibit nonspecific morphology and represent a diagnostic challenge. An approach to arriving at the correct diagnosis is presented. Most common etiologies are reviewed.

The management of lichen planus with low-molecular-weight heparin (enoxaparin)

The aim of this study is to evaluate the efficiency of low-dose, low-molecular-weight heparin (enoxaparin) in the treatment of lichen planus (LP). Twenty-four patients clinically and histopathologically diagnosed as LP with intense pruritus were treated with 3 mg of enoxaparin (Clexane), subcutaneously once a week for 4-14 weeks. Complete remission was observed in 20 of 24 patients (83%) who had widespread cutaneous involvement, but no or minimal effect was observed in four of 24 patients, three of whom had chronic hypertrophic LP. Low-dose enoxaparin was observed to be effective in the treatment of LP without any side-effects. Enoxaparin may be an effective and simple alternative therapy for LP.

Enoxaparin--a low molecular weight heparin, restores the altered vascular reactivity of resistance arteries in aged and aged-diabetic hamsters

We questioned whether the low molecular weight heparin enoxaparin acts upon the altered vascular reactivity of the resistance arteries in normal biological aging and in aging associated with diabetes. Experiments were performed on isolated resistance arteries of young (4 months old), aged (16 months old), and aged-diabetic hamsters (16 months old and 5 months since streptozotocin injection), and the reactivity was assessed by the myograph technique. The results showed that enoxaparin (60 microg/ml) had favorable effects on the vascular reactivity in aged and aged-diabetic conditions, i.e., diminished the contractility of the arterial wall to 10(-8)-10(-6) M noradrenaline (NA) and to K(+), and potentiated the impeded endothelium-dependent relaxation to 10(-8)-10(-4) M acetylcholine (ACh). The effect was more pronounced compared to that produced by unfractionated heparin (UFH). These pharmacological effects supplement the anticoagulant properties of enoxaparin and may be of relevance for improving perfusion/circulation in the microvasculature of aged and of aged-diabetic persons.

Oral lichen planus: an overview

Lichen planus (LP) is a chronic inflammatory muco-cutaneous disease. Since disorders of NK-cell functional activity could be observed in patients with LP, it is considered to be an autoimmune disease. The pathogenesis of LP is complex and not completely understood. The involvement of mucous membranes is frequently seen, usually asymptomatic, but occasionally complicated by extensive painful erosions, causing a considerable loss of quality of life. Patients with symptomatic oral lichen planus (OLP) often require intensive therapy to reduce the signs and symptoms of this painful and disabling inflammatory disease. OLP is considered to be a precancerous lesion for the development of squamous cell carcinomas. OLP is highly resistant to topical treatment and tends to pursue a chronic course with little tendency to spontaneous resolution. Until now meta-analysis provided little evidence for the superiority of the assessed interventions over placebo for palliation of symptomatic OLP.

Diagnosis and therapy of anogenital lichen planus

Genital lichen planus is a fairly common disease of genital skin that exhibits a widely variable morphology. Lichen planus occurring on the mucosal surfaces is chronic, and most often erosive and painful, frequently producing debilitating scarring. Mild, non-erosive disease is controllable with topical corticosteroids. Although erosive disease is much more difficult to manage, the use of topical corticosteroids, sometimes in combination with other topical or systemic medications, maximizes comfort and preserves function, especially with careful attention to local care and secondary infection.