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.