Discussion:
Plantar Ulcerative Lichen Planus is a rare form of lichen planus that
causes disability and numerous problems for patients (6). Various
treatments have been proposed for this type of disease, which have been
associated with varying degrees of recovery (5-8). In this article, we
present the case of a 52-year-old woman who had a large ulcer on the
sole of her foot that did not heal completely with previous treatments,
including cyclosporine, methotrexate, and triamcinolone acetonide
intralesional injection. She was then prescribed tofacitinib 5 mg
tablets to be taken twice a day, and as a result, the lesion has now
completely healed.
Janus Kinases play an essential role in the transmission of gamma
interferon signals, which are important mediators in the pathogenesis of
lichen planus. Based on this, the drug tofacitinib, which inhibits all
types of Janus kinases, should theoretically be effective in the
treatment of lichen planus (2). In a retrospective review study
published by Plante et al. in 2020, nine previous studies were examined
in which lichen planopilaris patients responded to oral and topical
treatments with tofacitinib. Among the studies reviewed, six studies
investigated oral tofacitinib, and in most cases, a daily dose of 10 mg
was prescribed (9).
It is worth mentioning that another study conducted by Damsky et al. in
2020 reported significant improvement in three patients with
treatment-resistant erosive lichen planus. These patients had not
responded to treatment with cyclosporine, methotrexate, acitretin,
prednisone, and mycophenolate mofetil, but showed a dramatic response to
treatment with tofacitinib at a dose of 5 mg twice a day (11).
Comparing the above study with our study, it is worth noting that our
study involved the plantar surface of the foot, while the other study
involved areas such as oral, penile, ocular, and vaginal mucous
membranes in three patients. The dose used in our study was similar to
the other study, and complete or near-complete treatment responses were
seen in both studies. It is also worth mentioning that the lesions in
both studies were resistant to previous treatments such as cyclosporine
and methotrexate.
In a case report study conducted by Kozlov et al. in 2023, a case of
severe esophageal lichen planus recovery after treatment with
tofacitinib was reported. The study introduced an 89-year-old woman with
lichen planus involving the skin, genital mucosa, mouth, and esophagus.
The patient’s esophageal lesions were resistant to treatment with
cyclosporine. While the patient did not respond well to the initial
treatment with tofacitinib at a dose of 5 mg daily, her dysphagia and
weight loss improved after receiving a dose of 5 mg twice a day (12).
The results of this study were consistent with our study, where both
studies showed improvement of the lesion and absence of side effects and
recurrence with a daily dose of 10 mg of tofacitinib. An important point
in this study is the necessity of receiving the appropriate dose of the
drug to control the lesions, as the lesions did not respond to a lower
dose of the drug (5 mg daily).
A case report study by Kilic et al. (2017) documented successful
treatment for erosive lichen planus with cyclosporine tablets in a
65-year-old woman with an erosive plaque on the sole of her foot. After
five months of treatment at a dosage of 3 mg/kg per day, the patient
showed significant improvement (4). However, the outcome of this study
differs from that of your study, as the patient’s lesion in Kilic et
al.’s study was erosive, while yours was ulcerative.
This difference in lesion type may explain the varying results observed
with the use of cyclosporine mist. It is possible that cyclosporine mist
could be effective in treating initial forms of erosive lichen planus
lesions in the soles of the feet, but its effectiveness could decrease
as the lesion progresses to the ulcerative form. However, further
comprehensive studies with appropriate sample sizes would be necessary
to confirm this hypothesis.
In the Salavastru study conducted in 2010, a significant improvement in
ulcerative lichen planus lesions on the soles of a 77-year-old woman was
noted after four weeks of treatment with tacrolimus ointment 0.1% twice
a day (8). However, the use of tacrolimus ointment in ulcerative lesions
presents a challenge of systemic drug absorption, and caution should be
taken in this regard.
Similarly, in the Kandula study conducted in 2018, a 56-year-old woman
presented with a painful ulcer on the metatarsal and plantar level of
the big toe, which responded dramatically to treatment with prednisone
tablets 40 mg daily in combination with clobetasol ointment 0.05% twice
a day for two weeks (6). However, the use of prednisone, particularly in
older individuals, can have serious side effects.
In addition to the drug treatments discussed in the reviewed studies,
surgical methods have also been reported to improve erosive and
ulcerative lesions of the soles of the feet in lichen planus disease.
For instance, Miotti et al. in 2020 reported successful treatment of
erosive lichen planus in the plantar area with autologous micrografts
and methotrexate tablets. The study involved a 65-year-old woman with a
6-year history of foot sole ulceration caused by erosive lichen planus,
who responded well to treatment with 15 mg of methotrexate tablets per
week and autologous skin grafting from the thigh area (7). However, this
study differs from ours since it combines drug therapy with surgery in
treating ulcerative lesions of lichen planus. It’s worth noting that
using invasive and surgical methods in lesion treatment may not be
acceptable to many patients.
If the effectiveness of these treatments is confirmed in wider studies,
each patient’s benefit and harm from each treatment method should be
calculated separately. The summary of studies on erosive and ulcerative
lichen planus in the sole area is presented in Table 1.
Table 1. Comparison of studies conducted on erosive and
ulcerative lichen planus in the sole area from 2010 to 2023.