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December 8, 2021

Treatment of Severe Nail Lichen Planus With Baricitinib

Author Affiliations
  • 1Department of Dermatology, University Hospital of Geneva, Geneva, Switzerland
JAMA Dermatol. 2022;158(1):107-108. doi:10.1001/jamadermatol.2021.5082

Nail lichen planus (NLP) is a notoriously difficult to treat nail disorder with high rates of therapeutic failures or relapses. In this article, we describe a case of severe recalcitrant NLP that improved with the use of oral baricitinib.

A woman in her 60s was evaluated for a severe nail dystrophy of all fingers of both hands that had started 1 year prior. Onychomycosis was ruled out by direct examination as well as results of a culture of nail specimens. Typical signs of NLP were observed, with longitudinal ridging and fissuring, distal splitting, and trachyonychia, which led to a clinical diagnosis of severe NLP. No other lichen planus (LP) lesions were noted on physical examination. Her NLP was previously treated with 5 intramuscular triamcinolone injections (40 mg per month) followed by oral acitretin, 25 mg, daily, for 5 months. Because there was no improvement, methotrexate was administered, which showed some efficacy but later was discontinued because of adverse effects, such as fatigue and a lowering of her work capacity. Treatment with baricitinib, 4 mg, daily, was then begun, and after 2 months, the appearance of her nails had substantially improved; after 6 months they were completely clear (Figure 1 and Figure 2). From the eleventh month of treatment, the daily dose was reduced to 2 mg. Four months later, we observed a minimal distal onycholysis on 1 finger that was compatible with a small recurrence (Figure 1, C). Despite the limited disease recurrence, the patient remained satisfied with her disease control and her dose was maintained at 2 mg, daily.

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