Lichen Planus and Lichenoid Dermatoses
Clinical Summary
Lichen Planus (Chronic/Refractory): Escalation and Emerging Targeted Therapies
-
Escalation triggers (lichen planus): Move beyond corticosteroids/phototherapy when quality of life is significantly impaired—e.g., severe pruritus (night waking), pain with urination, impaired eating, sexual dysfunction.
-
Emerging therapies: JAK inhibitors, PDE4 inhibitors, and IL-17/IL-23 biologics are described as rapidly effective and practice-changing, though access/coverage remains a barrier.
-
Individualized management: Screen for multisite involvement (oral, genital, esophageal, scalp); tailor therapy by subtype—e.g., liquid/injectable systemics for esophageal disease, suppositories/dilators for genital disease, and early systemic therapy for scalp (scarring risk).
Reviewed by Riya Gandhi, MA, Associate Editor of Immunology Group
Dr Melissa Mauskar discusses when to escalate treatment in chronic or refractory lichen planus based on quality-of-life impact and symptom burden. Learn how emerging targeted therapies—including JAK inhibitors, PDE4 inhibitors, and IL-17/IL-23 biologics—are transforming care, and get practical guidance on tailoring treatment by disease subtype, severity, and mucosal involvement.
Transcript
Hello, my name is Melissa Mauskar and I'm associate professor of dermatology with a co-appointment in the Department of Obstetrics and Gynecology at UT Southwestern Medical Center, where I'm the director of the Vulvar Health Program.
In chronic or treatment-resistant lichen planus, what clinical factors prompt you to escalate beyond traditional therapies like corticosteroids or phototherapy?
Dr Mauskar: The biggest thing is how these are affecting our patients' quality of life. So if they're waking up in the middle of night itching, if it affects their day-to-day activities, or if they can't eat, can't have sex, burn every time they go to the bathroom when they're trying to pee, that's when I'll definitely kick things up a notch.
How are emerging pathogenesis-driven treatments—such as JAK inhibitors, PDE4 inhibitors, or IL-17/IL-23 biologics—reshaping the management of lichenoid dermatoses
Dr Mauskar: These medicines are completely game changing. When we can get our patients on them, I cannot stress how quickly and effectively they improve our patient's care. I think the biggest thing is trying to get them covered. Lichen planus, lichenoid conditions, there are tons of people that have these conditions. And so I think whatever we can do to work with our pharmaceutical companies and work together, collaborate to do clinical studies so we can get these drugs approved to help our patients, I think would be game changing.
What practical guidance can you offer for individualizing therapy based on disease subtype, severity, or mucosal involvement?
Dr Mauskar: I think the first step is just remembering to ask. So when you see a patient that has lichen planus on their skin or in their scalp, ask about their oral and genital disease, ask if they have any difficulties swallowing or if things are getting caught in their throat when they're swallowing. Those are the biggest things. For me, it really depends on the patient's comorbidities. So a lot of my patients that have esophageal disease, I'll either give them liquid systemic therapies or do injection therapies, for instance, like methotrexate. However, if they have genital disease, I always either evaluate the vagina myself or ask a friend. If you don't feel comfortable doing that, you'll need to have both suppositories and dilators for mucosal disease, as well as systemic therapies. And finally, for hair disease, I was taught this as a trichologic emergency and we definitely want to get systemics on board before the damage is done and we have resulting scarring.
