Response of Lichen Planopilaris to Pioglitazone Hydrochloride

December 2019 | Volume 18 | Issue 12 | Case Reports | 1276 | Copyright © December 2019

Erik L. Peterson BS, Daniel Gutierrez MD, Nooshin K. Brinster MD,
Kristen I. Lo Sicco MD, Jerry Shapiro MD

The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, NY


Table 1 summarizes the characteristics of 23 patients with LPP who were treated with pioglitazone hydrochloride. All patients were referred from an outside dermatologist for specialty evaluation and care. The average age at diagnosis was 46.8, (range, 39-69 years). All patients were Caucasian. The mean treatment duration on pioglitazone was 10.68 months (range 2-20 months). The mean time to improvement after initiation of pioglitazone was 4 months (range 1-12 months). All those biopsied had histopathologic features consistent with LPP including inflammatory lymphocytic infiltrates, interface dermatitis, and progressive perifollicular fibrosis and hyperkeratosis. None had concurrent oral or nail lichen planus. Concomitant disorders included: androgenetic alopecia (4/23), hypothyroidism (3/23), alopecia areata (2/23), and dyslipidemia (2/23).

Prior to initiating therapy with pioglitazone, all were treated with one or more other agents. However, no patients were controlled with these treatments alone or in combination. The average number of medications employed during the stabilizing regimen was 7 (range 4-10). The average number of medications employed for the maintenance regimen was 4 (range 2-7). First and second line medications are listed in Table 2. Patients with significant symptoms, rapid progression of disease, or marked activity on trichoscopy were also initiated on systemic immunosuppression, such as hydroxychloroquine and doxycycline. As part of the therapeutic ladder for LPP, pioglitazone was added after first and second line medications failed to achieve stabilization.

Response to treatment was recorded at baseline and all following visits. Patients were evaluated by the investigators and assessed via objective measures of hairline measurements, photographs, and subjective measure of symptoms of pruritus, pain, or burning. In our cohort, 18 patients (78%) achieved improvement or stabilization of disease activity while 5 patients (22%) did not report benefits. One patient achieved minor regrowth. Mean time to stabilization after initiation of pioglitazone was 4 months (range, 1-12 months), with a mean treatment duration of 10.68 months (range, 4-20 months). No patient experienced significant adverse effects with either topical, intralesional, or systemic therapies. Several patients exhibited significant improvement with the addition of pioglitazone, after being refractory to other first line therapies. One such patient demonstrated improvement after 1 month of pioglitazone, complete cessation of disease activity after 2 months, and was stabilized on pioglitazone monotherapy for 12 months. Despite initial improvement on pioglitazone, three patients discontinued therapy citing concerns regarding the medication’s black box warning of increased risk of bladder cancer.