What is the best approach for managing nail lichen planus (LP) in a pediatric patient with a history of urticaria?

Management of Nail Lichen Planus in Pediatric Patients

For pediatric nail lichen planus, initiate treatment with intralesional triamcinolone acetonide 5-10 mg/cc as first-line therapy, regardless of the history of urticaria, as this provides the most effective approach to prevent permanent nail destruction. 1

First-Line Treatment Approach

Intralesional triamcinolone acetonide is the gold standard for isolated nail lichen planus, particularly when fewer than 3 nails are involved 2, 1. This approach is critical because:

• Nail LP can lead to permanent destruction with severe functional and psychosocial consequences, making prompt treatment essential even in mild cases 1
• Topical treatments have poor short-term efficacy and may cause long-term side effects in nail LP 1
• The dosing is 5-10 mg/cc, administered directly into the nail matrix 2, 1

Alternative Topical Approaches

If intralesional therapy is not feasible or for very mild disease, consider:

• Medium-potency topical corticosteroids showed complete or partial response in 64% of pediatric cutaneous LP cases 3
• High-potency topical corticosteroids (such as clobetasol 0.05%) can be applied under occlusion for nail involvement 2
• Topical vitamin D analogues combined with corticosteroids may be used, though evidence is primarily from nail psoriasis literature 2, 4

Important caveat: Monitor for clobetasol-related oral candidiasis, which occurred in the pediatric LP cohort 3

Systemic Therapy for Extensive or Refractory Disease

When more than 3 nails are affected or first-line therapy fails:

• Oral retinoids are second-line choices for nail LP 1
• Acitretin 0.2-0.4 mg/kg daily is recommended for extensive nail involvement 2
• Alitretinoin 30 mg daily showed marked improvement within 2-4 months in nail LP cases, though this requires further study 5
• Methotrexate can be considered for severe, refractory pediatric LP with multisite involvement 6

Critical warning: Early initiation of systemic therapy is recommended to prevent development of pterygium and permanent nail damage 5

Special Considerations for Urticaria History

The history of urticaria does not contraindicate standard nail LP treatments:

• Intralesional corticosteroids remain safe and appropriate 2, 1
• Antihistamines (H1 blockers) can be used concurrently if urticaria is active, as they are the mainstay of urticaria therapy 2
• Avoid systemic corticosteroids as monotherapy for prolonged periods, though short courses for severe disease are acceptable 2

Monitoring and Follow-Up

Thorough examination is essential because:

• Pediatric LP frequently involves multiple sites: 23% have oral involvement, 7.7% nail involvement, and 3.8% genital involvement 3
• 50% of pediatric LP lesions are pruritic, 19% painful, but 35% are asymptomatic, requiring careful inspection 3
• Most pediatric patients (81%) achieve remission with treatment or natural disease course 3

Treatment Algorithm Summary

1. <3 nails affected: Intralesional triamcinolone acetonide 5-10 mg/cc 2, 1
2. Mild disease or injection refusal: High-potency topical corticosteroids under occlusion 2
3. >3 nails or refractory disease: Oral retinoids (acitretin 0.2-0.4 mg/kg daily or alitretinoin 30 mg daily) 2, 1, 5
4. Severe multisite involvement: Consider methotrexate with multidisciplinary management 6

Key pitfall to avoid: Do not rely solely on topical therapy for nail LP, as it has poor efficacy and delays definitive treatment, risking permanent nail destruction 1