While we are amid a pandemic with the possible shortage of HCQ, dermatologists should be reminded that:
• The anti-inflammatory effect of HCQ may improve the clinical signs of LPP; however, administration of this drug is insufficient to prevent the subclinical disease progression.9 Dermatologists may discontinue the use of HCQ in responders after 1 year with monitoring the patients for recurrence or relapse.5
• Topical and intralesional super potent corticosteroids are recommended as the first-line treatment in localized LPP.4
• Oral cyclosporine followed by systemic corticosteroid may be the most effective medications in LPP; however, disease relapse may be detected.10 Mycophenolate mofetil has a more favorable safety profile compared to cyclosporine11 but the immunosuppressive nature of these medications necessitates extreme caution toward their administration during COVID-19 pandemic.12
• Acitretin (25 mg/day) may be an appropriate alternative since it has shown improvement in 66% of patients.7
• Pioglitazone (hypoglycemic drug, 15–30 mg/day) has shown some efficacy in the treatment of LPP and can be considered as an alternative to HCQ.4
• Tetracyclines antibiotics can also be considered as an alternative due to favorable outcomes in previous studies.13
In summary, lichen planopilaris is a primary cicatricial alopecia with irreversible sequels if left untreated. Psychosocial support of patients, raising their awareness of HCQ shortage during COVID- 19 pandemic, and offering available and safe alternatives, may prevent anxiety as well as disease flare up.
• The anti-inflammatory effect of HCQ may improve the clinical signs of LPP; however, administration of this drug is insufficient to prevent the subclinical disease progression.9 Dermatologists may discontinue the use of HCQ in responders after 1 year with monitoring the patients for recurrence or relapse.5
• Topical and intralesional super potent corticosteroids are recommended as the first-line treatment in localized LPP.4
• Oral cyclosporine followed by systemic corticosteroid may be the most effective medications in LPP; however, disease relapse may be detected.10 Mycophenolate mofetil has a more favorable safety profile compared to cyclosporine11 but the immunosuppressive nature of these medications necessitates extreme caution toward their administration during COVID-19 pandemic.12
• Acitretin (25 mg/day) may be an appropriate alternative since it has shown improvement in 66% of patients.7
• Pioglitazone (hypoglycemic drug, 15–30 mg/day) has shown some efficacy in the treatment of LPP and can be considered as an alternative to HCQ.4
• Tetracyclines antibiotics can also be considered as an alternative due to favorable outcomes in previous studies.13
In summary, lichen planopilaris is a primary cicatricial alopecia with irreversible sequels if left untreated. Psychosocial support of patients, raising their awareness of HCQ shortage during COVID- 19 pandemic, and offering available and safe alternatives, may prevent anxiety as well as disease flare up.
REFERENCES
1. Jakhar D, Kaur I. Potential of chloroquine and hydroxychloroquine to treat COVID-19 causes fears of shortages among people with systemic lupus erythematosus. Nat Med. 2020.
2. Fernandez AP. Updated recommendations on the use of hydroxychloroquine in dermatologic practice. J Am Acad Dermatol. 2017;76(6):1176-1182.
3. Zhou D, Dai S-M, Tong Q. COVID-19: a recommendation to examine the effect of hydroxychloroquine in preventing infection and progression. J Antimicrob Chemother. 2020.
4. Bolduc C, Sperling LC, Shapiro J. Primary cicatricial alopecia: Lymphocytic primary cicatricial alopecias, including chronic cutaneous lupus erythematosus, lichen planopilaris, frontal fibrosing alopecia, and Graham-Little syndrome. J Am Acad Dermatol. 2016;75(6):1081-1099.
5. Chiang C, Sah D, Cho BK, Ochoa BE, Price VH. Hydroxychloroquine and lichen planopilaris: efficacy and introduction of Lichen planopilaris activity index scoring system. J Am Acad Dermatol. 2010;62(3):387-392.
6. Rodriguez-Caruncho C, Marsol IB. Antimalarials in dermatology: mechanism of action, indications, and side effects. Actas Dermo-Sifiliográficas (English Edition). 2014;105(3):243-252.
7. Spencer LA, Hawryluk EB, English JC. Lichen planopilaris: retrospective study and stepwise therapeutic approach. Arch Dermatol. 2009;145(3):333- 334.
8. Van Beek MJ, Piette WW. Antimalarials. Dermatol Clin. 2001;19(1):147-160.
9. Donati A, Assouly P, Matard B, Jouanique C, Reygagne P. Clinical and photographic assessment of lichen planopilaris treatment efficacy. J Am Acad Dermatol. 2011;64(3):597-598.
10. Rácz E, Gho C, Moorman P, Noordhoek Hegt V, Neumann H. Treatment of frontal fibrosing alopecia and lichen planopilaris: a systematic review. J Eur Acad Dermatol Venereol. 2013;27(12):1461-1470.
11. Assouly P, Reygagne P. Lichen planopilaris: update on diagnosis and treatment. Paper presented at: Seminars in cutaneous medicine and surgery 2009.
12. Mehta P, McAuley DF, Brown M, Sanchez E, Tattersall RS, Manson JJ. COVID- 19: consider cytokine storm syndromes and immunosuppression. The Lancet.
13. Cevasco NC, Bergfeld WF, Remzi BK, de Knott HR. A case-series of 29 patients with lichen planopilaris: the Cleveland Clinic Foundation experience on evaluation, diagnosis, and treatment. J Am Acad Dermatol. 2007;57(1):47- 53.
2. Fernandez AP. Updated recommendations on the use of hydroxychloroquine in dermatologic practice. J Am Acad Dermatol. 2017;76(6):1176-1182.
3. Zhou D, Dai S-M, Tong Q. COVID-19: a recommendation to examine the effect of hydroxychloroquine in preventing infection and progression. J Antimicrob Chemother. 2020.
4. Bolduc C, Sperling LC, Shapiro J. Primary cicatricial alopecia: Lymphocytic primary cicatricial alopecias, including chronic cutaneous lupus erythematosus, lichen planopilaris, frontal fibrosing alopecia, and Graham-Little syndrome. J Am Acad Dermatol. 2016;75(6):1081-1099.
5. Chiang C, Sah D, Cho BK, Ochoa BE, Price VH. Hydroxychloroquine and lichen planopilaris: efficacy and introduction of Lichen planopilaris activity index scoring system. J Am Acad Dermatol. 2010;62(3):387-392.
6. Rodriguez-Caruncho C, Marsol IB. Antimalarials in dermatology: mechanism of action, indications, and side effects. Actas Dermo-Sifiliográficas (English Edition). 2014;105(3):243-252.
7. Spencer LA, Hawryluk EB, English JC. Lichen planopilaris: retrospective study and stepwise therapeutic approach. Arch Dermatol. 2009;145(3):333- 334.
8. Van Beek MJ, Piette WW. Antimalarials. Dermatol Clin. 2001;19(1):147-160.
9. Donati A, Assouly P, Matard B, Jouanique C, Reygagne P. Clinical and photographic assessment of lichen planopilaris treatment efficacy. J Am Acad Dermatol. 2011;64(3):597-598.
10. Rácz E, Gho C, Moorman P, Noordhoek Hegt V, Neumann H. Treatment of frontal fibrosing alopecia and lichen planopilaris: a systematic review. J Eur Acad Dermatol Venereol. 2013;27(12):1461-1470.
11. Assouly P, Reygagne P. Lichen planopilaris: update on diagnosis and treatment. Paper presented at: Seminars in cutaneous medicine and surgery 2009.
12. Mehta P, McAuley DF, Brown M, Sanchez E, Tattersall RS, Manson JJ. COVID- 19: consider cytokine storm syndromes and immunosuppression. The Lancet.
13. Cevasco NC, Bergfeld WF, Remzi BK, de Knott HR. A case-series of 29 patients with lichen planopilaris: the Cleveland Clinic Foundation experience on evaluation, diagnosis, and treatment. J Am Acad Dermatol. 2007;57(1):47- 53.
AUTHOR CORRESPONDENCE
Hamideh Moravvej MD Hamideh_moravvej@yahoo.com
