Successful treatment of nail lichen planus with topical tacrolimus.

Sir. Nail lichen planus (NLP) is characterized by thinning, longitudinal ridging and distal splitting of the nail plate (1.2). Although mild NLP is usually asymptomatic, deformation of the fingernails is cosmetically distressing. Failure to treat NLP results in nail loss or pennanent nail dystrophy in some cases. Therefore the condition should be treated etïectively in its early stage. NLP is usually resistant to topical corticosteroid therapy, but successful treatment has been reported with intralesional or systemic administration of corticosteroids (2-4). However, some patients are unable to tolerate the side-eftects of systemic corticosteroids. Topical tacrolimus has been reported as a safe, effective therapy for cutaneous (5, 6), oral (7-9) and vulvar lichen planus (LP) (9-11 ), even in patients whose lesions have shown recalcitrance to other treatments (7, 10). However, topical tacrolimus treatment for NLP has never been reported. We report here five cases of NLP treated successfully with tacrolimus ointment. topical corticosteroids. with no or slight improvement, before the tacrolimus therapy. In all the cases. 0.1 % topical tacrolimus {Protopic ointment 0.1%, Astelias Pharma Inc., Tokyo. Japan) was administered twice a day on one side of the nail plates and periungual regions of the fmgers and/or toes, and a topical corticosteroid (from the classification "very strong" or "strongest") was simultaneously started on the other side for a comparison of relative efficacy. In all cases, the affected nails treated with topical tacrolimus began to improve within 6 months after the initiation of treatment (mean 2.8 months; range 1-6 months), whereas no obvious changes, or only slight improvement, were observed in the nails treated with topical corticosteroids. suggesting that tacrolimus ointment had higher therapeutic efficacy than topical corticosteroids (Fig. 1). All the lesions were then treated uniformly with topical tacrolimus. All of the patients showed marked improvement (Fig. 2). Mild onycholysis and splitting of the nails remained in some of the patients. Reticular oral LP observed in a 58-year-old patient remained after his NLP lesions had improved. Two patients who discontinued topical tacrolimus application showed no exacerbation of their lesions at 16 and 36 months of follow-up, respectively. Two other patients continue to use topical tacrolimus once or twice daily as a supportive treatment, which keeps their lesions stable. The remaining patient stopped visiting our clinic after remission. No adverse effects were noted in any of the cases.