Combined Therapeutic Approach in Recalcitrant Generalised Lichen Planus Pigmentosus: A Case Report

Abstract

Introduction: Lichen planus pigmentosus (LPP) is a rare, chronic clinical variant. The generalised form is characterised by pruritic, hyperchromic macules and plaques with a brown-violaceous or greyish hue, distributed on the trunk and extremities, and is generally refractory to conventional treatments. Clinical Case: A 40-year-old female patient presents with a generalised, bilateral, and symmetrical dermatosis characterised by well-defined, pruritic, hyperchromic brown-violaceous macules and plaques that have been present for 20 years. Dermoscopy reveals a diffuse brown-greyish background and Wickham’s striae. Laboratory results were within normal limits, except for the lipid profile, which showed triglycerides of 165 mg, total cholesterol of 286 mg, LDL of 220 mg/dL, and HDL of 66 mg/dL. An incisional biopsy was performed, revealing hyperkeratosis, hypergranulosis, and irregular acanthosis, along with a moderate band-like lymphocytic inflammatory infiltrate. The patient reported having undergone repeated treatments with systemic and topical corticosteroids of moderate and high potency in recent years, with no improvement. Treatment was initiated with tacrolimus 0.1% every 12 hours, three times per week; metronidazole 250 mg every eight hours for 6 weeks; narrow-band UVB phototherapy for 30 sessions; and the statin atorvastatin 40 mg once daily for hypercholesterolaemia. Significant improvement in the lesions was observed at 12 weeks. Discussion: In refractory cases, combined therapeutic approaches are employed. These include topical calcineurin inhibitors, immunomodulatory agents, and systemic anti-inflammatory drugs such as metronidazole, narrow-band UVB phototherapy, and management of metabolic comorbidities. Conclusion: Treatment is based on a multifactorial approach, addressing both cutaneous inflammation and associated metabolic dysfunction.