Is Dupixent (dupilumab) an off-label indication for lichen planus?

Dupilumab (Dupixent) is an Off-Label Treatment for Lichen Planus

Yes, dupilumab (Dupixent) is currently an off-label indication for lichen planus. The FDA has not approved dupilumab specifically for the treatment of lichen planus, making its use for this condition off-label.

Current Treatment Recommendations for Lichen Planus

According to the most recent guidelines, the management of lichen planus follows a stepwise approach:

First-Line Treatments

• High-potency topical steroids (e.g., clobetasol 0.05% or fluocinonide 0.05%) 1
  • For mucosal disease: gel formulation
  • For scalp disease: solution formulation
  • For other affected areas: cream/lotion/ointment
• Topical tacrolimus (0.1% ointment) 1
• Oral antihistamines for pruritus 1

Second-Line Treatments

• Narrow-band UVB phototherapy (if available) 1
• Oral prednisone for moderate to severe cases 1
  • Treatment should continue until symptoms improve to Grade 1, then taper over 3 weeks

Third-Line/Severe Disease Options

• Acitretin (if no childbearing potential) 1
• Doxycycline in combination with nicotinamide 1
• Steroid-sparing immunosuppressants 1:
  • Azathioprine
  • Cyclosporine
  • Hydroxychloroquine
  • Methotrexate
  • Mycophenolate mofetil

Emerging Treatments for Refractory Lichen Planus

For cases resistant to conventional therapies, several newer agents have shown promise:

• JAK inhibitors like upadacitinib 2
• IL-17 inhibitors 1
• Tofacitinib 1

Dupilumab and Lichen Planus

Interestingly, there is a case report of dupilumab actually inducing lichen planus in a patient being treated for atopic dermatitis 3. This paradoxical reaction was attributed to dupilumab's mechanism of action:

• Dupilumab blocks the IL-4/IL-13 pathway, downregulating T-helper 2 (Th2) cell activation
• This creates a Th1/Th2 imbalance, potentially shifting toward a Th1-mediated immune response
• Lichen planus is primarily a T-cell mediated autoimmune disease where auto-cytotoxic CD8+ T cells trigger apoptosis of epithelial cells 4

Clinical Approach to Lichen Planus

1. Confirm diagnosis with biopsy to exclude dysplasia and malignancy 4
2. Assess severity based on:
   • Extent of involvement (body surface area)
   • Presence of mucosal involvement
   • Impact on quality of life
3. Begin with first-line therapies and progress as needed
4. Consider dermatology referral for severe or refractory cases 1

Important Considerations

• Drug-induced lichen planus should be considered in the differential diagnosis, with common culprits including beta-blockers, methyldopa, penicillamine, quinidine, and NSAIDs 5
• Lichen planus can be chronic and rarely undergoes spontaneous remission, particularly oral lesions 4
• Oral lichen planus is considered potentially premalignant, requiring careful monitoring 4

Pitfalls to Avoid

• Failing to distinguish between lichen planus and other lichenoid conditions like lichen sclerosus 1
• Using the outdated terms "leukoplakia" (which is merely descriptive) or "lichen planus et atrophicus" 1
• Overlooking the potential for drug interactions when using immunosuppressants in patients with comorbidities 1
• Neglecting to monitor for disease progression or malignant transformation in chronic cases

While dupilumab represents a potential option for refractory cases based on its immunomodulatory properties, its use for lichen planus remains off-label, and the paradoxical induction of lichen planus reported in some patients warrants caution.