Intralesional triamcinolone acetonide and topical calcipotriol-betamethasone dipropionate ointment for isolated nail lichen planus

Dear Editor,

Lichen planus is an autoimmune inflammatory dermatosis with unknown aetiology. According to the Philippine Dermatological Society-Health Information System, there were 90 recorded new cases of nail lichen planus from 2011 to 2022.^[1] Out of 67 patients in a 12-year study, 6% had isolated nail lesions, with 94% having fingernail involvement and 53.73% having toenails affected.^[2]

We report a 54-year-old female with isolated nail findings. One year prior, the patient noted a few brown linear streaks on bilateral great toenails, with no history of trauma or associated symptoms. No medications had been applied or taken, and no consultation was done. Thereafter, she developed ridging, loss of nail shine and brittleness of the left toenail, with the central area becoming thickened and elevated. Further brown-grey discolouration was noted. Six months later, there was spontaneous transverse splitting and separation of the proximal half of the right toenail, with the remaining nail left intact. There was also a separation of the distal and central parts of the left great toenail. Further pigmentation and thickening were noted. For the past three months, similar brown linear streaks were noted on bilateral thumbnails. The patient gave a history of exposure to wet work as a food vendor. She also had frequent exposure to cleaning agents such as bleach and detergents. She had manicures and pedicures 2–3 times/year. She mainly used loose footwear such as slippers and slip-on sandals. She also had a 5-year history of hypertension, diabetes and dyslipidaemia, treated with amlodipine, metformin and atorvastatin, respectively. The patient was a non-smoker, non-alcoholic and denied illicit drug use. There was no significant family history of similar lesions. She had one sexual partner without any history of sexually transmitted diseases. The review of systems was unremarkable.

Dermatologic examination showed nail ridging and splitting, trachyonychia and rough appearance, nail discolouration, detachment, subungual hyperkeratosis and scales. Onychoscopy revealed onychorrhexis, chromonychia, anonychia, leuconychia and subungual hyperkeratosis [Figures 1-3].

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Figure 1:

(a) Dermatologic examination shows distal nail splitting with longitudinal brown streaks on both thumbnails. (b) Polarised dermoscopy demonstrates longitudinal melanonychia, splinter hemorrhages on the lunula (black arrows), onychoschizia, transverse bands of leuconychia, and ragged cuticles.

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Figure 2:

Gross clinical appearance at weeks 0, 4, 8, 12 and 16 ([a-e]-great toe of the right foot, [f-j]-great toe of the left foot). Initially, there was brown-grey discolouration with a middle transverse fissure and a thin proximal nail plate on the right toenail (top). On the other hand, detachment of the nail from the distal nail bed, brown-white discolouration, subungual hyperkeratosis and surrounding thin white scales were observed on the left toenail (bottom). There was a gradual improvement in nail texture and discolouration on each follow-up.

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Figure 3:

Polarised onychoscopy for weeks 0, 4, 8 and 12 ([a-e]-great toe of the right foot, [f-j]-great toe of the left foot). There was initial trachyonychia, onychorrhexis, chromonychia, anonychia in the mid portion of the nail, onycholysis in the distal end of the more proximal newly growing nail, subungual hyperkeratosis and a fairly visible lunula on the right toenail (top). Meanwhile, the left toenail presented with trachyonychia, leuconychia, fragmentation and anonychia of the distal and central portion of the nail, subungual hyperkeratosis and a non-appreciable lunula. Growth of a normal-appearing nail plate was noted on the proximal area of both toenails. Follow-up evaluations demonstrated a steady improvement in both nail texture and discolouration. Persistence of nail loss, chromonychia and subungual hyperkeratosis was noted in some areas.

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Potassium hydroxide mount of nail clippings revealed no hyphae, ruling out onychomycosis. A 3-mm nail matrix punch biopsy showed histopathologic findings consistent with nail lichen planus [Figure 4]. There was an elevation of lymphocytes in the complete blood count. The thyroid function test was normal. She had elevated fasting blood glucose, cholesterol, triglycerides, very-low-density lipoprotein, uric acid and serum glutamic-oxaloacetic transaminase. There was haematuria in the urinalysis, and the chest radiograph revealed a tortuous and atheromatous aorta. These tests were done to rule out conditions associated with lichen planus, namely hepatitis, liver cirrhosis, dyslipidaemia, metabolic syndrome and thyroid disorders. She was then referred to an internist for a more holistic management.

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Figure 4:

Histopathologic results from the distal nail matrix biopsy. (a) Scanning magnification of the specimen. (b) Black dots represent hyperorthokeratosis in the stratum corneum. (c) Black dots in the epidermis show irregular acanthosis, while the white dots represent wedge-shaped hypergranulosis. (d) Black box shows dense band-like infiltrates of lymphocytes and histiocytes, with basal vacuolar alteration and dyskeratotic keratinocytes.

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The patient was started on topical calcipotriol and betamethasone dipropionate ointment twice daily for all affected nails. Triamcinolone acetonide (TAC) (10mg/ml) was injected in the nail matrix of both great toes. Topical lidocaine (2.5%) and prilocaine (2.5%) under occlusion was applied on the proximal nail folds an hour before injection. For the first three doses (week 0, 4 and 8) a volume of 0.1 mL was injected per nail, using a 1cc syringe with a 30g needle. De Berker’s technique was used, where two injections were administered on either side of the proximal nail fold, with the needle positioned 2 mm away from the proximal cuticle.^[3] Using the same concentration, the fourth dose was increased to 0.5 mL at week 12due to an initial slow response to the initial 0.1 mL.^[4] The only side effect noted was tolerable injection site pain. However, improvement could be observed in the clinical and onychoscopy photos [Figures 2 and 3].

Management of nail lichen planus remains difficult due to limited guidelines and unpredictable outcomes. Intralesional triamcinolone is recommended as first-line treatment for classical cases;^[3] while topical calcipotriol-betamethasone has shown efficacy in trachyonychia.^[5] This case shows the benefit of their combined use, adding to the scarce data available for this challenging disease. An important limitation was the difficulty in determining the independent effect of each modality. TAC is the established first-line treatment for nail lichen planus, supported by strong expert consensus;^[3] hence, much of the improvement seen may be due to TAC alone. Evidence for calcipotriol–betamethasone is based mainly on studies of trachyonychia,^[5] and its benefit in nail lichen planus remains uncertain. As both therapies were started at the same time, their individual contributions cannot be separately determined. Even so, reporting this experience remains useful, as treatment guidelines for isolated nail lichen planus are limited and real-world multimodal strategies may help guide clinical decision-making.

In conclusion, this case highlights the importance of early recognition and long-term follow-up of nail lichen planus, while emphasising the need for further research to establish standardised protocols and improve outcomes in patients with isolated nail disease.