From the Guidelines
Cyclosporin is a steroid-sparing immunosuppressant that can be considered for the treatment of moderate to severe lichen planus, particularly when other agents are ineffective or not tolerated. According to the NCCN guidelines 1, cyclosporin is one of the options for managing moderate lichen planus and lichenoid diseases, especially in severe cases where prednisone or intravenous methylprednisolone is recommended. The mechanism of action of cyclosporin involves suppressing the immune system by inhibiting calcineurin, an enzyme that activates T-cells, thereby reducing the production of inflammatory cytokines and interrupting the autoimmune process that causes lichen planus lesions.
Key Points to Consider
- Cyclosporin can be used systemically for severe or widespread disease, and treatment duration usually ranges from 8-12 weeks 1.
- Regular monitoring of blood pressure, kidney function, and drug levels is required due to potential side effects such as hypertension, nephrotoxicity, increased risk of infections, and hirsutism.
- Cyclosporin is generally reserved for severe, recalcitrant cases of lichen planus that haven't responded to corticosteroids or other first-line treatments due to these potential adverse effects and the need for careful monitoring during therapy 1.
Treatment Approach
- For mild lichen planus, treatment with immunotherapy can be continued, whereas for moderate or severe cases, treatment should be held 1.
- Rechallenge with immunotherapy can be considered when symptoms are controlled and if the extent of body surface area is <30%, especially if the patient is receiving a targeted biologic 1.
Important Considerations
- A referral to dermatology should be considered for patients with severe symptoms 1.
- Other agents that can be considered for the treatment of lichen planus include acitretin, doxycycline in combination with nicotinamide, and other steroid-sparing immunosuppressants such as azathioprine, hydroxychloroquine, methotrexate, and mycophenolate mofetil 1.
From the FDA Drug Label
Cyclosporine is a potent immunosuppressive agent that in animals prolongs survival of allogeneic transplants involving skin, kidney, liver, heart, pancreas, bone marrow, small intestine, and lung The effectiveness of cyclosporine results from specific and reversible inhibition of immunocompetent lymphocytes in the G0- and G1-phase of the cell cycle. T-lymphocytes are preferentially inhibited. Cyclosporine also inhibits lymphokine production and release including interleukin-2
The mechanism of action of cyclosporin in the treatment of lichen planus is likely due to its immunosuppressive effects, specifically the inhibition of T-lymphocytes and the reduction of lymphokine production, including interleukin-2. This suggests that cyclosporin may work by suppressing the immune response that contributes to the development of lichen planus. 2
From the Research
Mechanism of Action
- Cyclosporin works by suppressing the immune system, specifically inhibiting T-cell activation and proliferation, which are thought to play a key role in the pathogenesis of lichen planus 3, 4.
- The reduction in T-cell infiltrate in the skin and the abnormal expression of keratinocyte intercellular adhesion molecule-1 (ICAM-1) are accompanied by clinical improvement 4.
Efficacy in Lichen Planus Treatment
- Topical cyclosporine has been shown to be effective in the treatment of oral lichen planus, with significant improvements in symptoms and oral lesions after one month of therapy 3, 5.
- Oral cyclosporine has also been used to treat severe and refractory lichen planus of the skin, with sustained remission achieved in some patients 6, 4.
- The treatment response to cyclosporine can vary between individuals, with patients having high initial pain scores seeming to benefit the most from therapy 5.
Treatment Regimens
- Topical cyclosporine can be administered as a mouth rinse, with a dosage of 200 mg twice daily for four weeks, followed by a four-week withdrawal period 5.
- Oral cyclosporine can be given at a dosage of 6 mg/kg/day, with a response noted within 4 weeks and complete clearing achieved after 8 weeks of treatment 4.
- Cyclosporine can be used as part of a step-by-step approach to treating lichen planus, with the choice of medication depending on the type, extent, and severity of the disease 7.