What are the recommended new treatments for lichen planus?

New Treatments for Lichen Planus

For lichen planus, high-potency topical corticosteroids remain the cornerstone of treatment, with newer evidence supporting topical calcineurin inhibitors (tacrolimus 0.1%) as effective first-line alternatives, and emerging systemic options including low-dose methotrexate, IL-17 inhibitors, and JAK inhibitors (tofacitinib) for refractory cases. 1, 2, 3

First-Line Treatment Approach

Topical Corticosteroids (Standard of Care)

• Apply clobetasol propionate 0.05% gel for oral lesions or clobetasol 0.05% cream/ointment for cutaneous disease twice daily for 2-3 months, followed by gradual tapering over 3 weeks. 1, 2, 3
• For oral lichen planus specifically, gel formulations are mandatory as they provide appropriate mucosal adherence—cream or ointment formulations should never be used intraorally. 1, 3
• Alternative formulation: clobetasol 0.05% ointment mixed in 50% Orabase applied twice weekly for localized oral lesions. 1
• A 2021 network meta-analysis confirmed topical corticosteroids as the most effective drug class for treating oral lichen planus. 4

Topical Calcineurin Inhibitors (Newer First-Line Option)

• Tacrolimus 0.1% ointment is recommended as an alternative first-line option when corticosteroids are contraindicated or ineffective. 1, 2, 3
• Pimecrolimus demonstrated superior clinical resolution (OR: 14.7) and pain resolution (OR: 18.8) compared to placebo, though it carries higher risk of adverse effects than corticosteroids. 4

Emerging Systemic Treatments for Refractory Disease

Low-Dose Methotrexate (Newer Systemic Option)

• Low-dose methotrexate has substantial activity in oral lichen planus and should be considered for treatment-refractory cases. 5
• A retrospective study of 50 patients followed for over 2 years identified methotrexate as having substantial activity even in heavily pretreated patients. 5
• Typical dosing: 15 mg/week as a second-line systemic option. 6

Biologic Therapies (Newest Options)

• IL-17 inhibitors (secukinumab, ixekizumab) represent newer treatment options for refractory lichen planus, particularly when disease is dose-limiting. 6
• IL-12/23 inhibitors (ustekinumab) are recommended as first-line biologics for severe, refractory cases. 6
• TNF inhibitors (infliximab, etanercept, adalimumab, golimumab) are second-line biologic options. 6
• Anecdotal use of secukinumab in drug-induced lichen planus has been successful. 6

JAK Inhibitors (Novel Oral Option)

• Tofacitinib is a newer oral systemic option for refractory lichen planus. 6
• Listed as a second-line option alongside traditional immunosuppressants. 6

Other Systemic Immunomodulators

• Acitretin (0.2-0.4 mg/kg daily) remains a first-line systemic therapy for cutaneous lichen planus involving >3 nails. 6, 7
• Acitretin at 30 mg daily for 8 weeks has level B evidence (controlled clinical trial >20 participants). 7
• Azathioprine, cyclosporine A (3-5 mg/kg), and mycophenolate mofetil are second-line systemic options. 6, 8
• Hydroxychloroquine is ranked among alternative systemic treatments according to efficacy and side-effect profile. 8

Adjunctive and Alternative Newer Therapies

Phototherapy

• Narrow-band UVB phototherapy is an option for moderate to severe disease. 2, 3

Intralesional Therapy

• Intralesional triamcinolone acetonide (5-10 mg/cc) is effective for nail matrix involvement and refractory localized lesions. 6, 2

Combination Therapies

• Doxycycline with nicotinamide may be considered for refractory cases. 2, 3
• Ozonized water combined with corticosteroids showed superior clinical resolution (OR: 52) and pain resolution (OR: 9.9) compared to placebo. 4

Natural/Alternative Agents

• Purslane demonstrated clinical resolution (OR: 18.4) compared to placebo. 4
• Aloe vera showed pain resolution (OR: 13) compared to placebo. 4
• Hyaluronic acid demonstrated pain resolution (OR: 24.8) compared to placebo. 4

Critical Treatment Pitfalls to Avoid

• Never abruptly discontinue topical corticosteroids—taper gradually over 3 weeks to prevent rebound flares. 1, 3
• Never use cream or ointment formulations for oral mucosal disease; only gel formulations provide appropriate adherence. 1, 3
• Monitor patients using potent steroids for cutaneous atrophy, adrenal suppression, hypopigmentation, and contact sensitivity. 1
• Patients must wash hands thoroughly after application to avoid spreading medication to sensitive areas like eyes. 1

Treatment Algorithm for Refractory Cases

For patients failing topical therapy, follow this sequential ladder: 8, 5

1. Start with high-potency topical corticosteroids or tacrolimus 0.1% for 2-3 months 1, 2
2. Add oral antihistamines for moderate to severe disease 1, 2
3. Consider short course oral prednisone (15-30 mg for 3-5 days) for acute flares 1
4. Progress to low-dose methotrexate for persistent disease 5
5. Consider IL-12/23 inhibitors (ustekinumab) or IL-17 inhibitors (secukinumab, ixekizumab) for severe refractory cases 6
6. Alternative systemic options: tofacitinib, azathioprine, cyclosporine A, or mycophenolate mofetil 6, 8

Follow-Up and Monitoring

• Schedule follow-up at 3 months to assess treatment response and monitor for adverse effects. 1, 2
• If response is satisfactory, conduct final assessment at 6 months before discharge to primary care. 1
• Patients should report any persistent ulceration or new growth, as oral lichen planus carries a small risk of malignant transformation to squamous cell carcinoma. 1