Treatment of erosive oral lichen planus with methotrexate

Italian Consensus on the treatment of oral lichen planus

Oral lichen planus (OLP) is a chronic inflammatory condition of uncertain etiology affecting oral mucosae by T-cell mediated chronic inflammation. It affects between 1% and 3% of the global population, predominantly middle-aged adults (50-60 years), with a higher incidence in women. The immune response is thought to target keratinocytes, leading to cell death, particularly through CD8+ T lymphocytes. OLP manifests in various clinical forms, such as reticular, papular, erosive, and atrophic, with the reticular subtype being the most common. Erosive OLP is the most severe, characterized by widespread oral erosions, while atrophic OLP often follows erosive stages, affecting the tongue with a depapillated surface. Currently, no curative treatment exists for OLP, and the management focuses on symptom relief, including reducing pain and discomfort. Thus, a multidisciplinary approach involving dermatologists, oral surgeons, and dentists is often required. For this reason, the scientific community represented in Italy by the Mucosal Diseases Study Group of SIDeMaST (Italian Society of Dermatology and Venereology) reports its experience in the management of OLP, providing clinical recommendations for dermatologists based on the latest scientific evidence to optimize the treatment and management of OLP.

Systemic non-steroidal immunomodulators for oral lichen planus treatment-a scoping review

OBJECTIVE

The aim of this scoping review was to evaluate the efficacy and safety of the use of systemic nonsteroidal immunomodulators (SNSI) for oral lichen planus (OLP) treatment.

MATERIALS AND METHODS

This review was conducted according to PRISMA-ScR guidelines and registered at PROSPERO (CRD42021243524). Consulted databases were Pubmed, Embase, Scopus, and Web of Science. The inclusion criteria was as follows: clinical trials, case series, prospective, and retrospective studies conducted with participants presenting OLP of any sex and age.

RESULTS

Thirty-two studies were selected, assessing 9 different SNSI: methotrexate, dapsone, levamisole, hydroxychloroquine, thalidomide, metronidazole, azathioprine, mycophenolate mofetil, and colchicine. Methotrexate and dapsone were the drugs with the best evidence among the options included, regarding number and quality of studies. Methotrexate resulted in significant improvement in the clinical condition and remission of symptoms, ranging between 63 and 93% of cases. Dapsone presented a similar effect to the use of topical corticosteroids and tacrolimus CONCLUSION: Among SNSI therapeutic options, methotrexate, and dapsone showed promising efficacy and safety. However, large-scale randomized clinical trials are still needed.

CLINICAL RELEVANCE

SNSI have been used in the treatment of recalcitrant OLP; however, so far, it is not clear which are the best options. This scoping review highlights the potential use of methotrexate and dapsone.

Immune-mediated oral mucosal pathology: a comprehensive review and update for clinicians. Part I

The oral mucosa can be involved in a wide variety of mucocutaneous conditions that may present primarily in the mouth or affect other cutaneous or mucosal sites. Many of these conditions are immune mediated and typically present as inflammatory mucosal pathology. Patients experiencing such conditions usually seek medical evaluation and treatment due to the associated pain and discomfort and occasionally taste disturbance or dysphagia and the overall deterioration in the oral health-related quality of life. These conditions share some common features and there could be some overlapping in their clinical presentation, which can lead to delays in diagnosis and proper management of patients. Clinicians dealing with such disorders, including dermatologists, need to be aware of the oral manifestations of mucocutaneous conditions, their clinical features, underlying mechanisms, diagnostic approaches, and treatment options, as well as the recent advances in the research on these conditions. This review provides a comprehensive, evidence-based reference for clinicians, with updated insights into a group of immune mediated conditions known to cause oral mucosal pathology. Part one will cover oral lichen planus, erythema multiforme and systemic lupus erythematosus, while part two will cover pemphigus vulgaris and mucous membrane pemphigoid, recurrent aphthous stomatitis, in addition to the less common disorders linear IgA disease, dermatitis herpetiformis and epidermolysis bullosa.

Efficacy and safety of oral methotrexate versus oral mini pulse betamethasone therapy in the treatment of lichen planus: a comparative study

BACKGROUND

Lichen planus (LP) is a chronic inflammatory mucocutaneous disease. Systemic corticosteroids are the treatment of choice for generalized LP but their use is limited due to side effects. Oral mini pulse (OMP) therapy represents a good alternative. Also, Methotrexate (MTX) can be used as an alternative and safe modality in LP.

OBJECTIVES

To compare the efficacy and safety of oral MTX versus OMP betamethasone in the treatment of different types of LP.

PATIENTS AND METHOD

The study included 40 patients presenting with LP who were randomly divided into two groups. Group A for oral MTX 7.5 mg weekly & group B for OMP betamethasone 3 mg weekly for a maximum of 12 weeks. Basic laboratory investigations were done on both groups. Follow-up investigations were done on the 2nd, 4th, 8th and 12th weeks. The percentage of improvement in each patient was calculated on a scale according to the appearance of new lesions, degree of pruritus/pain, subsidence of cutaneous lesions and clearance of the oral lesion.

RESULTS

In the MTX group, 55% of patients showed excellent improvement, 25% showed good improvement and 20% showed partial improvement. In the OMP group, 85% of patients showed excellent improvement, 10% showed good improvement and 5% showed partial improvement. The reported clinical and laboratory adverse effects were tolerable and didn't lead to the discontinuation of treatment.

CONCLUSION

OMP betamethasone and low dose MTX may be considered effective and safe lines of treatment for different types of LP and may represent good and safe alternative options for conventional daily corticosteroid therapy.

Comparative Efficacy Study Combination of Oral Methotrexate and Prednisolone versus Oral Methotrexate in Patients with Lichen Planopilaris

Background

Lichen planopilaris (LPP) is a rare inflammatory disorder of the scalp that causes cicatricial alopecia. No therapeutic approach has been approved for this disease due to the rare frequency. Methotrexate and corticosteroid are commonly considered second- or third-line therapy. The efficacy of a combination of methotrexate and corticosteroid has been reported in some dermatological and immunological diseases. However, the efficacy of this combination in LPP is not clear. Therefore, this study aimed to compare the impact of methotrexate alone and in combination with corticosteroid on LPP.

Materials and Methods

This randomized clinical trial was performed on 28 patients who referred to the dermatology clinic affiliated with Isfahan University of Medical Sciences, Isfahan, Iran during February 2015-December 2016, and 24 of them completed the trials. Fourteen patients received 15 mg methotrexate per week alone and the other fourteen subjects received 200 mg prednisolone plus 15 mg methotrexate per week. The primary outcome was Lichen planopilaris activity index (LPPAI) score. Moreover, we evaluated photographic changes and symptoms during the study.

Results

The mean of LPPAI in both groups decreased during the follow-up with a similar pattern of LPPAI changes in both groups. No statistically significant difference was found between the two intervention groups regarding the LPPAI score. We found no difference in the symptoms and photographic assessments in methotrexate and combination therapy groups during follow-up. In both groups, exclusively one adverse effect was reported.

Conclusions

Our results showed that methotrexate therapy with and without corticosteroids had similar efficacy and safety.

Therapeutic strategies for oral lichen planus: State of the art and new insights

Oral lichen planus (OLP) is a chronic inflammatory disease of the oral mucosa. Several clinical subtypes of OLP have been reported, including the reticular and erosive one. On the one hand, reticular OLP is usually asymptomatic and is characterized by white streaks surrounded by well-defined erythematous borders. On the other hand, erosive OLP shows ulcerations and erosions surrounded by erythematous mucosa. While reticular OLP is relatively easy to control, erosive OLP is extremely painful and refractory to therapies, limiting the quality of life of the patients. In addition, treating erosive OLP is extremely tricky, and a gold standard treatment has not yet been established. However, several therapeutic approaches have been reported as effective, including systemic corticosteroids, systemic retinoids, and anti-interleukin (IL)-17/anti-IL-23 drugs. Indeed, our group and other several authors reported the effectiveness of anti-IL17, anti-IL12/23, and anti-IL23 agents in refractory OLP, highlighting the urgency of clinical studies on the use of anti-IL agents in OLP patients. In this paper, we reviewed the English- and German-language literature about therapeutic strategies for treating OLP, focusing on new systemic therapies for erosive OLP.

Lichen planus in Deutschland - Epidemiologie, Behandlung und Komorbidität. Eine retrospektive Krankenkassendatenanalyse

HINTERGRUND UND ZIELE

Lichen planus (LP) ist eine chronisch entzündliche Hauterkrankung, die eine große Belastung für die betroffenen Patienten darstellt. Es liegen jedoch nur wenige Daten zu dieser Erkrankung vor. Ziel dieser Studie ist es, das Wissen über die Epidemiologie und die Behandlungsmuster des LP anhand von Abrechnungsdaten deutscher Krankenkassen zu erweitern.

PATIENTEN UND METHODEN

Diese retrospektive Beobachtungsstudie nutzte die InGef-Forschungsdatenbank. Es wurden prävalente und inzidente LP-Patienten aus den Jahren 2015 und 2018 identifiziert. Für demografische Charakteristika, Behandlungsmuster und Komorbidität wurden deskriptive Statistiken berechnet.

ERGEBNISSE

Die Prävalenz des LP lag bei 95,9 und die Inzidenz bei 20,1 pro 100 000 Personen im Jahr 2018, was 79 605 prävalenten LP-Fällen in Deutschland entspricht. Die erste LP-Diagnose wurde in der Regel von einem Dermatologen oder Hausarzt gestellt. Drei Viertel der inzidenten und die Hälfte der prävalenten Patienten erhielten eine topische Therapie, meist ohne zusätzliche systemische Therapie. Die Komorbidität des LP stand im Einklang mit bereits bekannten Assoziationen.

SCHLUSSFOLGERUNGEN

Die verfügbaren Therapieoptionen sind nach wie vor begrenzt, was den ungedeckten Bedarf an sicheren und wirksamen systemischen Behandlungsmodalitäten unterstreicht. Der LP ist häufig mit klinisch relevanter systemischer Komorbidität verbunden. Zusammengenommen könnten diese Beobachtungen zu einem verbesserten Verständnis der Krankheitslast führen und das diagnostische Bewusstsein für diese Erkrankung unter Klinikern schärfen.

Lichen planus in Germany - epidemiology, treatment, and comorbidity. A retrospective claims data analysis

BACKGROUND AND OBJECTIVES

Lichen planus (LP) is a chronic inflammatory skin disease and is a major burden for affected patients. However, data on this condition are scarce. This study aims to expand the knowledge on the epidemiology and treatment patterns of LP using German health claims data.

PATIENTS AND METHODS

This retrospective observational study was based on the InGef research database. Prevalent and incident LP patients were identified in the years 2015 and 2018. Descriptive statistics were calculated for demographic characteristics, treatment patterns, and comorbidity.

RESULTS

The prevalence of LP was 95.9 and the incidence was 20.1 per 100,000 individuals in 2018, corresponding to 79,605 prevalent LP cases in Germany. The first LP diagnosis was generally documented by a dermatologist or a primary care physician. Three-quarters of the incident and half of the prevalent patients received topical therapy, mostly without further systemic therapy. Comorbidity in LP patients was consistent with previously known associations.

CONCLUSIONS

Available treatment options remain limited, underscoring the unmet need for safe and efficacious systemic treatment modalities. Lichen planus is frequently accompanied by clinically relevant systemic comorbidity. Taken together, these observations may improve our understanding of the burden of this disease and increase diagnostic awareness among clinicians.

Prevalence and risk of chronic kidney disease in oral lichen planus: a large cross-sectional study from eastern China

Background

Oral lichen planus (OLP) is a chronic inflammatory mucocutaneous disease which is frequently associated with comorbidities such as diabetes and cardiovascular diseases. However, little is known about the association of OLP with impaired kidney function. To elucidate the possible association of chronic kidney disease (CKD) with OLP and its severity, this study investigated the prevalence of CKD as well as its risk factors in patients with OLP.

Methods

A large prospective cross-sectional study of 1,021 patients with OLP was carried out using questionnaires and laboratory tests available from an oral medicine clinic at a university in eastern China. According to the Kidney Disease: Improving Global Outcomes (KDIGO) diagnostic guideline, CKD was classified based on the estimated glomerular filtration rate (eGFR, <60 mL/min/1.73 m²) or urinary albumin to creatinine ratio (UACR, >30 mg/g).

Results

The prevalence of CKD in the patients with OLP in this study was 14.3% (95% CI, 12.3–16.6%), which was higher than that in the general Chinese population (10.8%; 95% CI, 10.2–11.3%). The mean values of serum creatinine, eGFR, UACR, and urine N-acetyl-β-D-glucosidase in patients with CKD were significantly higher than those in patients without CKD (all P<0.01). Pearson’s correlation analysis revealed that CKD stage and UACR were positively correlated with the severity of OLP (both P<0.001). Importantly, multivariate regression analysis revealed that age ≥58 years old, female sex, and hypertension were independent risk factors for incident CKD and abnormal UACR (>30 mg/g) in patients with OLP (all P<0.01).

Conclusions

This study has reported for the first time that CKD is a comorbidity in patients with OLP. The occurrence and staging of incident CKD are associated with OLP and its severity.

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.

Oral lichen planus: a novel staging and algorithmic approach and all that is essential to know

Lichen planus (LP) is a chronic autoimmune disease. Oral lesions may occur in isolation or in combination with other affected muco-cutaneous sites. Oral LP (OLP) may present as one of the various manifestations of LP or may present as a disease sui generis with a broad range of severity. Despite this disease targeting the oral mucosa, its great impact on quality of life is underrated. In this article, we provide an updated review of the pathophysiology and epidemiology of OLP and offer guidance for its diagnosis and management. We also propose an algorithmic approach to the clinical forms of OLP and a novel staging system to facilitate management decisions.

Clinical Efficacy and Safety of Methotrexate versus Hydroxychloroquine in Preventing Lichen Planopilaris Progress: A Randomized Clinical Trial

BACKGROUND

Lichen planopilaris is an inflammatory cicatricial alopecia, and its management is a challenge for dermatologists. We aimed to compare the efficacy of methotrexate and hydroxychloroquine on refractory lichen planopilaris.

METHODS

In a randomized clinical trial, 29 patients were randomly allocated to receive either 15 mg methotrexate/week or 200 mg hydroxychloroquine twice a day for 6 months. Side effects, symptoms/signs, and laboratory tests were assessed periodically. Lichen Planopilaris Activity Index (LPPAI) was measured before intervention and at 2, 4, and 6 months after. The changes from baseline to the end of the study were analyzed within each group and between the two groups by per-protocol and intention-to-treat analysis.

RESULTS

After 2 months, mean (standard deviation [SD]) decrease in LPPAI in methotrexate group was significantly more than that in hydroxychloroquine group (1.68 [1.24] vs. 0.8 [0.71], respectively, P = 0.047). Furthermore, after 6 months, mean (SD) decrease in LPPAI in methotrexate group was significantly higher than that in hydroxychloroquine group (3.3 [2.09] vs. 1.51 [0.91], respectively, P = 0.01). The following symptoms/signs showed significant improvements in frequency and/or severity in methotrexate group after intervention: pruritus (P = 0.007), erythema (P = 0.01), perifollicular erythema (P = 0.01), perifollicular scaling (P = 0.08), spreading (P = 0.001), and follicular keratosis (P = 0.04). In hydroxychloroquine group, only erythema (P = 0.004) showed significant improvement.

CONCLUSIONS

Methotrexate was more effective than hydroxychloroquine in treating refractory lichen planopilaris.