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A 27
years old young unmarried man presented with diffuse pruritic skin lesion on his
dorsal surface of both feet. He was suffering for last 12 years. Both the
lesions were very pruritic, violaceous, hyperkeratotic, dark colored and little
bit oozy due to severe scratch. There was no other similar lesion or the
mucosal involvement. His nails and hair were also normal. Patient was in
irregular treatment and took topical steroid ointment and antihistamine but not
much improvement. According to clinical presentation patient was diagnosed as
Lichen planus. No biopsy was taken because the patient did not consent to take
biopsy. We did hematological examination and found CBC within normal limit,
SGPT and Creatinine found normal, IgE was little bit higher than normal limit. The
patient was initially treated with Normal Saline soak 2 times daily and
Acitretin 25 mg daily for 2 months with topical steroid. Patient shows better response.
After 2 months patient was unable to carry on the actretin therapy due to high
treatment cost. After that we started apremilast 30 mg daily for 2 months then
we started 30 mg apremilast on alternate days for 3 months. We checked his
liver and kidney function by checking the blood parameter which was normal.
Patient’s condition was good enough but not totally cured. Then we continued
the apremilast treatment another 2 months at the same dose. After 11 months
patient was totally cured and shows no major adverse effect except weakness.
Keywords: Lichen planus, Apremilast,
Acitretin, Pruritic, Violaceous
Abbreviations: LP: Lichen Planus; NS: Normal Saline; SGPT: Serum
Glutamic Pyruvic Transaminase; CBC: Complete Blood Count
INTRODUCTION
Lichen
planus, a papulosquamous disease, in its classical presentation is characterized
by pruritic violaceous papules most commonly on the extremities. It also is
accompanied by involvement of oral and genital mucous membrane. Course of LP is
generally self-limited for a period of several months to years, but it may last
long. Persistant LP is a premalignant condition. Lichen planus is non-contagious.
CASE REPORT
A 27 years old young unmarried man presented with diffuse pruritic skin
lesion on his dorsal surface of both feet. He was suffering for last 12 years.
Both the lesions were very pruritic, violaceous, hyperkeratotic, dark colored
and little bit oozy due to severe scratch. There was no other similar lesion or
the mucosal involvement. His nails and hair were also normal. Patient was in
irregular treatment and took topical steroid ointment and antihistamine but not
much improvement. According to clinical presentation patient was diagnosed as
Lichen planus. No biopsy was taken because the patient did not consent to take
biopsy. We did hematological examination and found CBC within normal limit,
SGPT and S. Creatinine found normal, IgE was little bit higher than normal
limit. The patient was initially treated with Normal Saline soak 2 times daily
and Acitretin 25 mg daily for 2 months with topical steroid. Patient shows
better response. After months patient was unable to carry on the actretin
therapy due to high treatment cost. After that we started apremilast 30 mg
daily for 2 months then we started 30 mg apremilast on alternate days for 3
months. We checked his liver and kidney function by checking the blood parameter
which was normal. Patient’s condition was good enough but not totally cured.
Then we continued the apremilast treatment another 2 months at the same dose.
After 11 months patient was totally cured and shows no major adverse effect
except weakness.
DISCUSSION
Lichen planus (LP) is a chronic
mucocutaneous inflammatory disease. Lichen planus was first described by
Erasmus Wilson in 1869. It involves skin, mucous membrane, hair, nail. Skin
lesions are accompanied with severe pruritus [1-4]. The pathogenesis remains
unclear but it thought to be an autoimmune phenomenon. Diagnosis of Lichen
planus is usually clinical. However histological evidence is also important [5].
Cutaneous Lichen planus may spontaneously resolve, often within a year [6]. The
use of acitretin has been proved highly effective in Lichen planus. Some
authors consider acitretin as a first line therapy at a dose of 0.5-0.7 mg/kg
until remission is achieved and at a dose of 0.3-0.5mg/kg thereafter, either as
monotherapy or in combination with topical or systemic corticosteroid [7].
Acitretin a second generation retinoids, which activates certain retinoic acid
receptor, subtypes to control epidermal maturation and skin inflammation.
However, acitretin is highly teratogenic, thus a strict contraception has to be
applied up to three years after treatment. Mucocutaneous side effects, like
xerosis cutis, mucosae, hair loss, dyslipidemia and elevation of liver enzymes
are reversible after discontinuation [8]. Systemic corticosteroids are
considered as a second line therapy for Lichen planus [9]. 3
recalcitrant cases of oral lichen planus that were effectively treated with
apremilast, a drug recently approved for psoriasis and psoriatic arthritis [10].
Ten patients with biopsy-proven LP received 20 mg of apremilast orally twice
daily for 12 weeks with 4 weeks of treatment-free follow-up. The primary efficacy
end point was the proportion of patients achieving a 2-grade or more improvement
in the Physician Global Assessment (PGA) after 12 weeks of treatment [11]. It has been seen that
15%-20% of patients with LP demonstrate a relapsing and remitting course, often
resistant to most conventional modalities of treatment.
CONCLUSION
Though persistent Lichen planus is a
premalignant condition, it can be successfully treated with acitretin and
apremilast with topical corticosteroid.
1.
Wolf R,
Ruzicka T, Rupec RA (2010) Pleomorphismusdes lichen ruber – Klinische
variationsbreite, pathogenese under therapies. The Chameleon’s many faces –
clinical spectrum, pathogenesis and therapy of Lichen planus. Akt Dermatol 36: 180-185.
2.
Le Cleach
L, Chosidow O (2012) Lichen planus. N
Engl J Med 366: 723-732.
3.
Brebmer
F, Haenssle HA, Schon MP, Emmert S (2011) Response of recalcitrant Lichen planus to alitretinoin in 3
patients. J Am Acad Dermatol 65: 58-60.
4.
Alsenaid
A, Lang A, Ruzicka T, Braun-Falco M, Wolf R (2013) Lichen planus with associated myasthenia gravis - Successful
treatment with acitretin. Eur J Dermatol 23: 909-910.
5.
Vazirnia
A, Cohen PR, Philip R (2014) Acitretin for the management of generalized
cutaneous Lichen planus. Dermatol
Online J 20: 2.
6.
Asch S,
Goldenberg G (2011) Systemic treatment of cutaneous Lichen planus: An Update. Cutis 87: 129-134.
7.
Gunther S
(1975) Lichen ruber planus and Lichen ruber verrucosus of the skin:
Therapeutic results using vitamin A acid in 98 patients. Z Hautkr 50: 59-68.
8.
Alamri A,
Alsenaid A, Ruzicka T, Wolf R (2016) Hypertrophic Lichen planus – Successful treatment with acitretin. Dermatol Ther
29: 173-176.
9.
Kossard
S, Artemi P (2000) Acitretin for hypertrophic Lichen planus like reaction in a burn scar. JAMA Dermatol 136:
591-594.
10.
https://doi.org/10.1016/j.jaad.2012.07.014
68:255-261
11.
Bubna AK
(2016) Apremilast: A dermatologic perspective. Department of Dermatology, Sri
Ramachandra University, Chennai, Tamil Nadu, India. Indian J Drugs Dermatol 2:
75-82.
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