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.