Alleviation of isolated nail lichen planus by the JAK1/2 inhibitor Baricitinib: a case report

JAK Inhibitors and Inflammatory Nail Disorders: A Systematic Review of Clinical Outcomes and Therapeutic Potential

BACKGROUND

Inflammatory nail disorders can have a significant impact on patients' quality of life owing to aesthetic and functional concerns. They are also challenging to treat because the therapeutic armamentarium is quite limited. This systematic review aims to report the efficacy and safety of Janus kinase and Tyrosine kinase 2 inhibitors in treating these conditions.

METHODS

We conducted a comprehensive search on PubMed, Cochrane, and Embase Library to find eligible case reports, case series, single-arm clinical trials, and randomized controlled trials. We used the following search terms from inception until 15 December, 2024: "nail" AND "jak inhibitors" OR "tofacitinib" OR "baricitinib" OR "abrocitinib" OR "ruxolitinib" OR "deuruxolitinib" OR "upadacitinib" OR "ritlecitinib" OR "deucravacitinib" (nine searches in total).

RESULTS

Of 441 articles found, 31 were included in this study. The most extensively studied drug was tofacitinib, followed by baricitinib, deucravacitinib, upadacitinib, and abrocitinib. Janus kinase/Tyrosine kinase 2 inhibitors demonstrated improvements in inflammatory nail conditions, with generally mild adverse events (nasopharyngitis and transient laboratory abnormalities being most common). The topical formulation of tofacitinib, the only one studied in these nail diseases, also demonstrated promising results with minimal systemic absorption and no side effects.

CONCLUSIONS

This review highlights Janus kinase/Tyrosine kinase 2 inhibitors as a valuable addition to the therapeutic arsenal for inflammatory nail disorders while emphasizing the importance of safety assessments and tailored treatment approaches. The long-term safety of Janus kinase/Tyrosine kinase 2 inhibitors still needs further investigation and the potential for adverse events emphasizes the need for tailored therapeutic strategies, including more studies on topical formulations.

Janus kinase 1 inhibitor abrocitinib for isolated nail lichen planus: a case report and literature review

AIM

This study aims to evaluate the efficacy and safety of the Janus kinase 1 (JAK1) inhibitor abrocitinib for treating nail lichen planus (NLP) and to review available case reports documented in English.

METHODS

We reported the first case of a patient with isolated NLP treated with the selective JAK1 inhibitor abrocitinib. The patient received 100 mg of oral abrocitinib daily.

RESULTS

After 6 months, the patients showed 82.35% improvements in the Dermatology Life Quality Index (DLQI) and 79.17% improvement in the Nail lichen planus severity index (tNLPSI), which were consistent with the clinical improvement, correlating with clinical improvement. In the subsequent 6 months, the dose was reduced to 100 mg every other day, with further improvement in onycholysis.

CONCLUSIONS

This case suggests that abrocitinib can be both safe and effective for treating NLP.

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.

Therapeutic Response of Alopecia Areata-Associated Nail Changes to Baricitinib

Nail changes are seen in some individuals with alopecia areata, with the most common variants including pitting and trachyonychia. The nail findings are presumed to be due to the same lymphocytic infiltration seen in hair bulbs in individuals with AA. Baricitinib is an immunomodulatory drug that acts as a selective and reversible inhibitor of JAK proteins and is indicated for adult patients with moderate to severe rheumatoid arthritis who have not responded to other disease-modifying antirheumatic drugs. The FDA has also approved baricitinib to treat patients hospitalized with COVID-19 and severe alopecia areata. In this report, we present a case of a patient with persistent AA-associated nail changes who has been successfully treated with baricitinib. The patient has been suffering from alopecia for several years. She presented with periungual inflammation in conjunction with persistent fingernail ridges and pitting of her right fourth digit. The nail dystrophy persisted despite treatment with tacrolimus ointment, clobetasol ointment, or oral fluconazole. Patient was started on a trial of baricitinib for alopecia areata, which was the suspected cause of the nail changes. After 4 months of treatment with baricitinib, the patient's nail showed mild improvement of nail dystrophy with some clubbing and pitting still present. Within 11 months of treatment, her nail was normalized in appearance and texture. There are no established guidelines to treat AA-associated nail changes. Our patient's AA-associated nail changes were normalized after 11 months of treatment with baricitinib. Further research is needed to determine which alopecia areata patients may benefit from treatment with baricitinib and when treatment should be initiated. Baricitinib may be an effective treatment option for AA-associated nail changes in some patients.