INTRODUCTION
Lichen planus is an auto-inflammatory skin disorder marked by intensely pruritic, violaceous papules that commonly affect the extremities of middle-aged adults.1 Though a clear pathogenic mechanism remains unknown, some of the proposed etiologies implicate dermal T-lymphocytes and cytokines, including interferon-gamma, interleukin-1, and interleukin-2.1 First-line treatment options consist of corticosteroids, retinoids, and phototherapy.1 Other medications with reported benefits include methotrexate,2 metronidazole,3 and sulfasalazine.4 Though they have not been FDA-approved for lichen planus, Janus kinase (JAK) inhibitors have garnered increasing attention for their successful therapeutic intervention in immune-mediated dermatologic diseases.5 Herein, we present a case of refractory, biopsy-proven lichen planus successfully treated with the oral JAK1 inhibitor, upadacitinib.
A CASE REPORT
A 46-year-old female presented to our clinic at Mount Sinai Hospital with 8 months of biopsy-proven lichen planus refractory to multiple treatments. She complained of severe pruritus of lesional skin, resulting in functional impairment, difficulty sleeping, and disrupted focus in her daily activities. On physical exam, diffuse violaceous, flat-topped papules were seen bilaterally on the arms (Figure 1 A1-A2), wrists, thighs, legs, and groin. The oral mucosa was clear of lesions. Failed treatments included trials of metronidazole, prednisone, sulfasalazine, and methotrexate, as well as topical betamethasone dipropionate and permethrin. Isotretinoin had been attempted but was denied by her insurance.
Upadacitinib was started at the dose of 15 mg by mouth once daily. In addition, she was supplemented with hydroxyzine as needed for pruritus at bedtime and topical tacrolimus ointment.
