Diagnosis and Emerging Treatments for Nail Lichen Planus

The transcript discusses nail lichen planus as a difficult condition because it can cause scarring of the nail matrix and significant patient morbidity, while historically offering few effective treatments. Diagnosis can be straightforward in advanced scarring cases such as pterygium, but milder presentations with redness, inflammation, hyperpigmentation, and onycholysis may resemble psoriasis or other inflammatory nail disorders. The speaker highlights capillaroscopy as a promising diagnostic tool that may help distinguish nail lichen planus from psoriasis and potentially reduce the need for biopsy. Treatment evidence remains limited, with intralesional and systemic steroids representing the strongest, though still modest, evidence base. The speaker describes a 2024 case series in which low-dose naltrexone at 3 mg daily led to major improvement in most biopsy-proven cases, with apparent lack of response in patients with trachyonychia. Practical prescribing advice is given: because naltrexone comes as 50 mg tablets, it usually must be compounded into 1–5 mg doses, though a makeshift oral suspension can be prepared if needed. The talk also reviews emerging JAK inhibitor therapy, including topical ruxolitinib and compounded tofacitinib, but emphasizes stronger results with oral JAK inhibitors such as tofacitinib, baricitinib, abrocitinib, and upadacitinib, including cases of near-normal nail regrowth and remission. Overall, the speaker suggests capillaroscopy, low-dose naltrexone, and especially oral JAK inhibitors as important future directions for management.