Efficacy of oral retinoids in treatment-resistant lichen planopilaris
2014; Elsevier BV; Volume: 71; Issue: 5 Linguagem: Inglês
10.1016/j.jaad.2014.06.013
ISSN1097-6787
Autores Tópico(s)Cutaneous lymphoproliferative disorders research
ResumoTo the Editor: Lichen planopilaris (LPP) is classified as a primary lymphocytic cicatricial alopecia.1Kang H. Alzolibani A.A. Otberg N. Shapiro J. Lichen planopilaris.Dermatol Ther. 2008; 21: 249-256Crossref PubMed Scopus (94) Google Scholar Topical and intralesional corticosteroids, oral tetracyclines, and oral hydroxychloroquine are considered by many as first-line agents in LPP followed by agents such as mycophenolate mofetil and cyclosporine1Kang H. Alzolibani A.A. Otberg N. Shapiro J. Lichen planopilaris.Dermatol Ther. 2008; 21: 249-256Crossref PubMed Scopus (94) Google Scholar, 2Assouly P. Reygagne P. Lichen planopilaris: update on diagnosis and treatment.Semin Cutan Med Surg. 2009; 28: 3-10Crossref PubMed Scopus (163) Google Scholar, 3Baibergenova A. Donovan J. Lichen planopilaris: update on pathogenesis and treatment.SkinMed. 2013; 11: 161-165PubMed Google Scholar Current literature suggests oral retinoids may benefit some patients with cutaneous lichen planus. However, the role of oral retinoids in treating LPP is unclear. Ethics board approval was obtained to retrospectively evaluate the effectiveness of oral retinoids in treating patients with LPP who failed or had an incomplete response to 1 or more first-line agents. Patients were from the University of Toronto Hair Clinic over the years 2009 through 2013. Response rates to retinoids were determined; secondary end points included time to response, side-effect profiles, and concomitant treatments. Of 189 patients evaluated with biopsy-proven LPP, 21 patients (17 female, 4 male) were prescribed treatment with oral retinoids after other treatments failed to halt disease progression (ie, incomplete response). Of the 21 patients, the mean age of disease onset was 47.3 years, whereas the mean duration of disease at the time of assessment was 8.8 years. During the course of therapy, 12 patients were treated with acitretin, 8 with isotretinoin, and 1 patient had a period of treatment with each drug (Table I). The vast majority of patients previously received or was receiving treatment with topical or injectable steroids, and other oral immunosuppressives/immunomodulators (Table I). Presence of 1 or more of the following criteria was used as an indicator of treatment response (clinical improvement): (1) improvement in erythema, scaling, or hyperkeratosis; or (2) cessation of hair shedding; or (3) conversion of individuals with a positive pull test result to a negative pull test result. Five of 21 (24%) of patients with treatment-resistant LPP were deemed to benefit from adjunctive oral retinoid therapy with an approximate time of 2 to 4 months to clinical improvement. Other concurrent treatments were maintained at the same dose or decreased after the addition of retinoids, which made it possible to attribute the clinical benefit to the retinoid therapy. Of the responders, 3 received acitretin, and 2 received isotretinoin. Notably, 4 of 5 responders had lichen planus at other body sites (Table I).Table ISummary of demographics, treatment regimen, and responsePatientAge (y), sexOther sites LPPreviously ineffective treatments (duration in months)Concurrent treatment before addition of retinoid (duration in months)Specific retinoid addedResponse to retinoid143, MNoneHCQ (25)MMF (8)DOXY (7)CLOB (16)PRED (5)ISOClinical improvement at 2 mo; response maintained to 8 mo followed by relapse252, FR hand, R shoulder, L legNoneCLOB (18)HCQ (16)ISOClinical improvement at 3.5 mo; response maintained to 15-mo follow-up350, FNailsPIO (7)CLOB (22)TAC (12)HCQ (19)ACIClinical improvement at 4 mo; response maintained to 18-mo follow-up458, FEars, nose, lip, nailsHCQ (21)DOXY (6)CsA (7)ILK (14)CLOB (25)Finasteride (54)ACIClinical improvement at 4 mo; response maintained to 6 mo followed by relapse567, FAxilla, legs, pubicNoneHCQ (19)CLOB (24)MINOX (13)ILK (16)ACIClinical improvement at 4 mo; response maintained to 13-mo follow-up640, FNoneHCQ (17)DOXY (13)CLOB (19)ILK (11)OCP (× years)ISONo response after 6 mo743, FNoneDOXY (7)HCQ (24)CLOB (13)ILK (3)OCP (× years)TAC (8)ISONo response after 8 mo845, FNoneCLOB (13)ILK (3)DOXY (9)HCQ (22)MMF (4)TAC (7)NoneISONo response after 5 mo949, MNoneDOXY (4)PRED (3)HCQ (23)ILK (9)CLOB (18)ISONo response after 9 mo1050, FOral, nail, legsCLOB (22)ILK (13)DOXY (4)HCQ (15)MMF (7)NoneISONo response after 6 mo1168, FOralILK (11)HCQ (8)CLOB (14)ISONo response after 5 mo1268, FNoneCLOB (22)ILK (15)DOXY (2)HCQ (16)MMF (3)CsA (4)NoneACI (3 mo)ISO (5 mo)ACI not well tolerated and stopped at 3 moNo response after 5 mo ISO1336, MNoneILK (2)DOXY (6)HCQ (16)CLOB (21)ACINo response after 7 mo1453, FVulvarCLOB (4)TAC (13)ILK (14)DOXY (8)HCQ (17)MMF (3)NoneACINo response after 5 mo1556, FOral, nailsCLOB (2)PRED (5)ILK (18)HCQ (16)FLUO (22)ACINo response after 10 mo1659, FNoneCLOB (3)ILK (15)DOXY (8)HCQ (22)CsA (4)NoneACINo response after 4 mo; stopped because of increased lipids1761, FL buccal mucosaCLOB (13)DOXY (1)HCQ (6)ILK (33)PIO (6)ACINo response after 7 mo1862, FArm, legs, oralDOXY (13)HCQ (17)ILK (22)CLOB (12)ACINo response after 6 mo1972, FNoneILK (4)HCQ (16)MMF (7)CLOB (26)ACINo response after 9 mo2073, FNoneHCQ (14)CLOB (17)ILK (9)ACINo response after 5 mo2174, FNoneDOXY (8)CLOB (24)ILK (31)HCQ (12)ACINo response after 8 moACI, Acitretin (25-50 mg orally daily); CLOB, topical clobetasol; CsA, cyclosporine (5 mg/kg); DOXY, doxycycline (100 mg orally twice a day); F, female; FLUO, topical fluocinolone acetonide oil; HCQ, hydroxychloroquine (400 mg orally daily, to maximum 6.5 mg/kg); ILK, intralesional triamcinolone acetonide (5 mg/mL) every 3-4 mo; ISO, isotretinoin (1 mg/kg); L, left; LP, lichen planus; M, male; MINOX, minoxidil 5% topical; MMF, mycophenolate mofetil (1000 mg orally twice a day); OCP, oral contraceptive; PIO, pioglitazone (15-30 mg orally daily); PRED, oral prednisone (0.5-1 mg/kg); R, right; TAC, topical tacrolimus. Open table in a new tab ACI, Acitretin (25-50 mg orally daily); CLOB, topical clobetasol; CsA, cyclosporine (5 mg/kg); DOXY, doxycycline (100 mg orally twice a day); F, female; FLUO, topical fluocinolone acetonide oil; HCQ, hydroxychloroquine (400 mg orally daily, to maximum 6.5 mg/kg); ILK, intralesional triamcinolone acetonide (5 mg/mL) every 3-4 mo; ISO, isotretinoin (1 mg/kg); L, left; LP, lichen planus; M, male; MINOX, minoxidil 5% topical; MMF, mycophenolate mofetil (1000 mg orally twice a day); OCP, oral contraceptive; PIO, pioglitazone (15-30 mg orally daily); PRED, oral prednisone (0.5-1 mg/kg); R, right; TAC, topical tacrolimus. The most common side effect of oral retinoid therapy reported within the study was dryness of the skin and mucosae (43%). Other side effects included hypercholesterolemia (14.2%), headaches (9.5%), and increased serum transaminases (4.7%). Only 3 of 5 responders ultimately remained on oral retinoids with a 13- to 18-month follow-up interval. The remaining 2 patients had discontinued oral retinoid therapy because of relapse and further progression of the disease. Overall, we found oral retinoid therapy to be a helpful adjunctive treatment in only a small proportion of those with treatment-resistant LPP. Our data series of 21 patients represents one of the largest to date to evaluate the role of oral retinoids in the treatment of LPP. A benefit of retinoid therapy was found in 2 of 3 patients reported by Spencer et al.4Spencer L.A. Hawryluk E.B. English III, J.C. Lichen planopilaris: retrospective study and stepwise therapeutic approach.Arch Dermatol. 2009; 145: 333-334Crossref PubMed Scopus (43) Google Scholar In contrast, 6 patients reported by Assouly and Reygagne2Assouly P. Reygagne P. Lichen planopilaris: update on diagnosis and treatment.Semin Cutan Med Surg. 2009; 28: 3-10Crossref PubMed Scopus (163) Google Scholar did not show improvement.2Assouly P. Reygagne P. Lichen planopilaris: update on diagnosis and treatment.Semin Cutan Med Surg. 2009; 28: 3-10Crossref PubMed Scopus (163) Google Scholar Our study is limited by its retrospective nature. Furthermore, given that retinoid therapy is not a first-line treatment in our clinic setting, the study group is small despite the relatively large numbers of patients we evaluated with LPP during the study period. Further study is required to determine what factors contribute to the efficacy of retinoids in LPP.
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