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Chapter 9: Pityriasis Lichenoides Chronica

Christopher N. Nguyen; Auris O. Huen

PITYRIASIS LICHENOIDES CHRONICA

Therapeutic Approach

Pityriasis lichenoides chronica (PLC) is an uncommon, inflammatory skin disease characterized by small red or brown scaly papules diffusely on the trunk and extremities. PLC lies on the chronic, indolent end of the pityriasis lichenoides spectrum, opposite to pityriasis lichenoides et varioliformis acuta (PLEVA). The etiology is unknown, with a T-cell mediated reaction triggered by an infection or drug as a leading hypothesis. Because PLC may display T-cell clonality, there is question of a connection or overlap with lymphoproliferative disorders. There are few therapeutic trials for PLC, with most evidence based on uncontrolled case series and retrospective reviews. As a result, there are no FDA-approved therapies. Due to the possibility of an infectious etiology, antimicrobials and anti-inflammatories are used sometimes with efficacy. Since PLC is a self-limited condition, treatment is based on cosmetic and symptomatic improvement. However, PLC usually follows a relapsing course over months to years. At our institution, limited PLC is treated with topical steroids. For extensive disease, phototherapy with topical steroids is first line, while antimicrobials, such as doxycycline, with topical steroids is second line. Lastly, we reserve methotrexate for recalcitrant cases. See Table 9-1.

Table 9-1Pityriasis Lichenoides Chronica Treatment Table
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Table 9-1 Pityriasis Lichenoides Chronica Treatment Table
MEDICATION NAME POPULATION STUDIEDa MECHANISM OF ACTION DOSING ADVERSE EFFECTS SUGGESTED MONITORING LEVEL OF EVIDENCE (REFERENCE)
Topical Therapy
Steroids AC Anti-inflammatory Low (eg, hydrocortisone 2.5% ointment/cream) to super high potency (eg, clobetasol 0.05% ointment/cream) depending on location and size of lesion; apply BID Skin atrophy, striae, telangiectasia, hypopigmentation None III1-2
Calcineurin inhibitors C Anti-inflammatory Tacrolimus 0.03-0.1% ointment, pimecrolimus 1% cream; apply BID Skin irritation None III3-4
Systemic Therapy
Erythromycin AC Anti-inflammatory, antimicrobial 30-50 mg/kg/d for 2-6 mob GI upset None III2,5
Azithromycin A Anti-inflammatory, antimicrobial 500 mg/d on d 1 then 250 mg/d on d 2-5; bimonthly-monthly for 6 mob GI upset None III6
Tetracycline A Anti-inflammatory, antimicrobial 1-2 g/d for 1-2 mob Contraindicated in pregnancy, <8 yo; photosensitivity, GI upset, esophagitis, headache None III7
Doxycycline A Anti-inflammatory, antimicrobial 100-500 mg BID for 2-6 mo† Contraindicated in pregnancy, <8 yo; photosensitivity, GI upset, esophagitis, headache None III8
Minocycline A Anti-inflammatory, antimicrobial 100 mg QD-BID for 2-6 mob Contraindicated in pregnancy, <8 yo; headache, lupus, skin/teeth pigmentation None III2,9
Bromelain A Anti-inflammatory 40 mg TID for 1st mo, 40 mg BID for 2nd mo, 40 mg QD for 3rd mo GI upset None IIB10
Acyclovir C Anti-viral 40-80 mg/kg/d divided TID-QID for 7-14 db Headache, nausea, renal dysfunction None IIB11
Valacyclovir A Anti-viral 500-1000 mg TID for 7-14 db Headache, nausea, renal dysfunction None IIB11
Methotrexate A Anti-inflammatory 7.5-25 mg/wk Leukopenia, photosensitivity, oral ulcers, nausea, increased liver enzymes, pneumonitis Baseline CBC and CMP, then monthly for first ...

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