Azathioprine for the treatment of severe erosive oral and generalized lichen planus.

Sir, oral mucosal as well as skin lesions had a good response. One patient with oral mucosal lesions along with generalized skin Lichen planus is usually a benign and self-limiting disease but in some patients the disease may be severe and unremitting, involvement had a poor response (40%) to the therapy. This patient took the drug for 3 months only and did not report requiring therapeutic interventions. The etiopathogenesis of lichen planus is not exactly known but circumstantial evidence for further follow-up. All the patients who responded to treatment had started showing improvement within 4–6 weeks suggests that it is an immunologically mediated disease with an lymphocytotoxic eVect (1, 2). Various treatment modalities of initiating the therapy. On follow-up, one patient developed bleeding from the gums due to gingivitis. None of the other such as corticosteroids, dapsone, PUVA, griseofulvin, retinoids and cyclosporine, etc., have been tried (3–5). Of these, only patients reported any side eVects. There were no changes in laboratory parameters in any of the patients. Out of 7 patients systemic corticosteroids have been widely used and usually found to be eVective, even in severe disease. However, these with complete healing of the lesions, none had had a relapse over the 6–9 months’ follow-up period after stopping treatment modalities often require to be given over a long period, which can result in serious side eVects (6). Severe treatment. generalized lichen planus also responds to systemic corticosteroids when used in high doses, often resulting in side eVects DISCUSSION owing to prolonged use. Azathioprine has been shown to be an eVective corticosteroid-sparing agent in a few such patients Azathioprine has been used in many dermatological diseases with severe generalized involvement (7–9). We evaluated the such as pemphigus, bullous pemphigoid, connective tissue eVectiveness of this drug in a larger series of patients with diseases, chronic actinic dermatitis, psoriasis and pyoderma severe erosive oral and/or generalized lichen planus. gangrenosum as a corticosteroid-sparing, immunosuppressive agent (10, 11). A few reports have shown its eVectiveness in severe generalized and erosive mucosal lichen planus unreMATERIAL AND METHODS sponsive to other modalities of treatment (7–9). When used Nine patients (4 males, 5 females, 5–54 years of age; mean 32.2 years) in this situation, azathioprine probably acts by inhibiting the with clinical diagnoses of severe erosive oral lichen planus and/or T-lymphocytes. In the past we used azathioprine in one patient generalized lichen planus were included in the study. The duration of with unresponsive, generalized and severe lichen planus, with the disease in these patients varied from 3 months to 4 years. The a dramatic improvement in 12 weeks and without any side diagnosis in each patient was made on the characteristic morphology of skin/mucosal lesions, conŽ rmed by skin/mucosal biopsy. Baseline eVects (7). Encouraged by the results, we decided to carry out investigations including a complete hemogram with platelet counts, an open study in patients with severe erosive oral and genrenal and liver function tests, blood sugar tests, chest X-ray, routine eralized lichen planus. Out of 9 patients, 7 showed excellent urine and stool examination and ECG were done in all the patients responses, one showed a good response and only one patient before starting treatment. Patients with deranged renal/liver function tests, with any focus of infection, and pregnant and lactating mothers had a poor response. There were no side eVects of the therapy. were excluded from the study. The patients were treated with azathioThe drug is metabolized by three competiting enzymes, hypoxprine, 50mg twice daily orally (about 2mg/kg day), for a period anthine-guanine phosphoribosyl transferase, xanthine oxidase varying from 3 to 7 months (average 5 months). Complete hemograms and thiopurine methyl transferase (TPMT) (12), but its conwith platelet counts, liver and renal function tests were repeated every version into inactive metabolites is mainly done by TPMT. 4 weeks. All patients were clinically evaluated every 4 weeks to assess the therapeutic response, which was determined by  attening of the Therefore the patients with low TPMT levels are at a major lesions, appearance of new lesions and change in severity of itching. risk of developing myelotoxicity, gastrointestinal and hepatic Mucosal lesions were assessed in terms of  attening/healing of the side eVects. About one in 200–300 people in the general lesions and decrease in severity of irritation and burning sensation. population are deŽ cient in this enzyme. Determination of The response to therapy was considered to be excellent if there was an overall 75–100% improvement in the lesions and itching/irritation, TPMT levels in patients before initiating this therapy would good if it was 50–75% and poor if it was less than 50%. facilitate the exclusion of such susceptible individuals. If such a facility is not available, a regular hemogram is recommended to detect early myelosuppression. We used this drug in patients RESULTS who had air-borne contact dermatitis due to weed Parthenium, with very good results and minimal side eVects even when it Out of 9 patients, 4 patients had only oral mucosal lesions, 3 had oral mucosal as well as skin lesions and the other 2 had was continuously used for 2–3 years (13). We also investigated the long-term toxicity of the drug with regular monitoring of generalized skin lesions. Within 3 to 7 months (average 5 months) of azathioprine therapy, 7 (77.8%) patients had an hematological, hepatic and renal parameters in these patients (14). We therefore suggest that azathioprine may be used as excellent response, which included 4 patients with mucosal lesions, one with oral as well as skin lesions and two patients an alternative drug to systemic corticosteroids in patients with severe/generalized lichen planus. It is safe and better tolerated with generalized skin lesions; one (11.1%) patient who had