Rapid resolution of generalized lichen planus by tofacitinib: Assessment by polarized and ultraviolet-induced fluorescence dermoscopy

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Lichen planus (LP) is a chronic, T-cell-mediated inflammatory disorder affecting the skin, mucosa, hair, and nails. LP commonly presents as violaceous, polygonal, flat-topped papules and plaques on the flexor surface of extremities, associated with intense pruritus. Although involvement of intertriginous areas and genitalia is uncommon, it may lead to diagnostic uncertainty and therapeutic resistance. Therapeutic ladder for generalized LP includes systemic corticosteroids, retinoids, and immunosuppressants such as methotrexate and azathioprine.^[1]

The Janus kinase-signal transducer and activator of transcription (JAK-STAT) pathway has emerged as a key factor in LP development, which supports the use of JAK inhibitors, including tofacitinib, for treatment.^[2,3]

Dermoscopy serves as a useful, non-invasive tool for diagnosing LP and treatment response as well. Classically, it shows Wickham’s striae, dotted and short linear vessels which disappear after successful treatment.^[4] However, ultraviolet-induced fluorescent (UVF) dermoscopic assessment is not described in the literature. We report a case of generalized LP involving the genitalia extensively. It was successfully treated with short-term oral tofacitinib and a short course of systemic corticosteroids and assessed by both polarized and UVF dermoscopy.

A 29-year-old male presented with severe pruritic, hyperpigmented papules and plaques involving extremities, thighs, and genitalia for 5 months [Figures 1 and 2]. The lesions were associated with intense itching. There was no evidence of mucosal damage or nail abnormalities. No history of long-term medications for any systemic illness. Examination revealed violaceous to grayish papules and plaques on the scrotum, inner thighs, and extremities. Dermoscopic analysis was done using both polarized and UVF modes. Lesions on the scrotum revealed annular and linear Wickham striae, dotted vessels, brown dots, and scales in polarized mode [Figure 1], and annular and linear bluish-green fluorescence in UVF mode [Figure 1]. While lesions on the thighs showed Wickham striae, focal yellow areas, white rosettes, scales, and dotted and short linear vessels in polarized mode [Figure 2], and linear and diffuse bluish-green fluorescence in UVF mode [Figure 2]. Based on clinical and dermoscopic features, a diagnosis of LP was made.

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Figure 1:

(a) Clinical image of lichen planus showing violaceous papules and plaques on the scrotum and thighs. The box indicates the site of dermoscopy. (b) Dermoscopy shows annular (yellow arrows) and linear (black arrow) Wickham striae, and scales (white arrow). Dotted vessels (black box) and brown dots (yellow circle) are well appreciated. [DermLite 5,10×, Polarized mode]. (c) Dermoscopy shows annular and linear (green arrows) bluish-green fluorescence. [DermLite 5,10×, ultraviolet induced fluorescent mode].

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Figure 2:

(a) Clinical image of lichen planus showing violaceous papules and plaques on the scrotum and thighs. The box indicates the site of dermoscopy. (b) Dermoscopy shows Wickham striae (black arrow), focal yellow areas (white arrows), white rosettes (white box), and scales (black star). Note the dotted (black circle) and short linear (black box) vessels. [DermLite 5,10×, Polarized mode]. (c) Dermoscopy shows linear (green arrows) and diffuses bluish-green fluorescence. [DermLite 5,10×, ultraviolet-induced fluorescent mode].

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Blood investigations such as complete blood count, random blood sugar, liver function tests, renal function tests, lipid profile, echocardiography, and Mantoux test were within normal limits. The patient was prescribed oral tofacitinib 5 mg twice daily for 4 weeks.

He also received oral betamethasone, 1 mg daily for 3 days, followed by 0.5 mg daily for the next 4 days. Topical mometasone was prescribed along with oral levocetirizine 5 mg once daily at night. The treatment was well tolerated, with no significant adverse effects.

After 4 weeks of treatment, the patient demonstrated significant resolution of the lesions [Figures 3 and 4], with marked reduction in the pruritus. Dermoscopy of the scrotum in polarized mode revealed the absence of Wickham striae and scales; only gray pigment dots and focal areas of pink hue were noted on a brownish-gray background [Figure 3]. While thigh lesions revealed gray pigment dots on a brownish background [Figure 4]. UVF dermoscopy in both lesions showed a black area without fluorescence [Figures 3 and 4]. Only Tofacitinib was continued for another 3 weeks. Treatment-related complications and relapse of lesions were not noted during follow-up for 3 months.

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Figure 3:

(a) Clinical image after treatment showing resolution of the lesion with post-inflammatory hyperpigmentation. Violaceous papules and plaques on the scrotum and thighs. The box indicated the site of dermoscopy. (b) Dermoscopy shows the absence of Wickham striae and scales. Gray dots (black box) and focal pink hue (yellow star) are noted on a grayish-brown background. [DermLite 5,10×, Polarized mode]. (c) Dermoscopy shows a diffuse black area without fluorescence. [DermLite 5,10×, ultraviolet-induced fluorescent mode].

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Figure 4:

(a) Clinical image after treatment showing resolution of the lesion with post-inflammatory hyperpigmentation. Violaceous papules and plaques on the scrotum and thighs. The box indicated the site of dermoscopy. (b) Dermoscopy shows the absence of Wickham striae and scales. Gray dots (black circle) and a focal pink hue on a brown background are noted. [DermLite 5,10×, Polarized mode]. (c) Dermoscopy shows a diffuse black area without fluorescence. [DermLite 5,10×, ultraviolet induced fluorescent mode].

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Cytotoxic T-lymphocytes activate LP by attacking basal keratinocytes while interferon-gamma and other cytokines drive the disease development.^[3] The JAK-STAT signaling pathway activates the inflammatory process, which explains why JAK inhibitors serve as treatment options for LP. Tofacitinib, which inhibits JAK 1/3 enzymes, has proven to be effective for treating multiple dermatoses that involve inflammation and autoimmunity, especially in lichen planopilaris.^[5]

The treatment resulted in the almost complete disappearance of lesions. The adjunctive use of systemic corticosteroids may have contributed to rapid symptom control and early suppression of inflammation. However, tofacitinib produced a prolonged immunosuppressive effect to prevent relapse. A biopsy was not done because dermoscopy demonstrated specific features of LP.^[6] Dermoscopy proved to be a valuable objective tool both in the diagnosis and monitoring treatment response. This case adds to the growing evidence supporting the role of tofacitinib as a targeted therapeutic agent in generalized LP.

To conclude, short-term oral tofacitinib together with a short course of systemic corticosteroid resulted in complete remission of LP lesions and pruritus. Dermoscopy aided the diagnosis. This implies that the pathogenesis of LP should be revisited, as tofacitinib could be added to the therapeutic ladder. Research needs to be continued for developing a treatment protocol managing LP with tofacitinib by recruiting a larger sample size.