What are the treatment options for nail lichen planus?

Treatment Options for Nail Lichen Planus

Intralesional triamcinolone acetonide (5-10 mg/cc) should be considered the first-line therapy for nail lichen planus, especially when fewer than 3 nails are involved. 1

First-Line Treatment Options

Localized Disease (<3 nails affected)

• Intralesional therapy:

  • Intralesional triamcinolone acetonide 5-10 mg/cc 1, 2
  • Target: Inject into nail matrix for matrix involvement, nail bed for bed involvement
  • Frequency: Every 4-6 weeks until improvement is noted
  • Efficacy: 80% of patients show limitation or regression by the third injection 3

• Topical therapy:

  • High-potency topical corticosteroids (clobetasol 0.05% or fluocinonide 0.05%) 1, 4
  • Topical tacrolimus 0.1% ointment 1, 5, 4
  • Application: Apply to affected nail folds twice daily
  • Note: Topical treatments have poor short-term efficacy when used alone 2

Widespread Disease (>3 nails affected)

• Systemic therapy:
  • Acitretin 0.2-0.4 mg/kg daily (contraindicated in women of childbearing potential) 1, 2
  • Prednisone (for moderate to severe cases) 1, 4
  • Doxycycline with nicotinamide (for moderate cases) 1

Second-Line Treatment Options

• Steroid-sparing immunosuppressants:

  • Azathioprine 1
  • Cyclosporine (3-5 mg/kg) 1, 5
  • Methotrexate (15 mg/week) 1, 5
  • Mycophenolate mofetil 1, 5
  • Hydroxychloroquine 1, 5

• Biologic therapies (for severe, treatment-resistant cases):

  • IL-17 inhibitors (secukinumab, ixekizumab) 1
  • TNF-alpha inhibitors (etanercept) 5
  • JAK/STAT inhibitors (tofacitinib) 1, 5

• Other options:

  • Bath-PUVA 5
  • Apremilast 1
  • Nail lacquer containing urea (20%), keratinase, and hydroxipinacolone retinoate - showed 81% reduction in nail lichen planus severity score after 12 weeks in a small study 6

Treatment Algorithm Based on Disease Severity

1. Mild disease (1-2 nails):

   • Start with intralesional triamcinolone acetonide 5-10 mg/cc
   • Combine with high-potency topical corticosteroids or tacrolimus 0.1%

2. Moderate disease (3-5 nails):

   • Intralesional triamcinolone for the most severely affected nails
   • Add oral prednisone if significant inflammation is present
   • Consider acitretin if no childbearing potential
   • Consider doxycycline with nicotinamide

3. Severe disease (>5 nails or pterygium formation):

   • Acitretin 0.2-0.4 mg/kg daily (if no childbearing potential)
   • Systemic corticosteroids for acute flares
   • Consider steroid-sparing immunosuppressants (cyclosporine, methotrexate)
   • For treatment-resistant cases, consider biologics (IL-17 inhibitors)

Important Clinical Considerations

• Early treatment is crucial: Nail lichen planus can lead to permanent destruction with severe functional and psychosocial consequences 2
• Pediatric cases: Nail lichen planus can affect children (40% in one study), and early diagnosis and treatment may limit scarring 3
• Duration of treatment: Lichen planus may resolve spontaneously within 1-2 years, but nail involvement tends to be more persistent and resistant to treatment 4
• Monitoring: Regular follow-up is essential to assess treatment response and adjust therapy accordingly
• Pterygium formation: This represents advanced disease and is more difficult to treat, emphasizing the importance of early intervention 3

Pitfalls and Caveats

• Topical treatments alone have limited efficacy for nail lichen planus 2
• Systemic treatments carry more significant side effects and should be used with caution
• Acitretin is contraindicated in women of childbearing potential due to teratogenicity
• Intralesional injections can be painful and may require local anesthesia
• Treatment response is often slow, and patients should be counseled about realistic expectations
• Regular monitoring for adverse effects of systemic medications is essential

Early diagnosis and prompt treatment are critical to prevent permanent nail damage and improve quality of life for patients with nail lichen planus.