Management of Nail Lichen Planus: Steroids, Low-Dose Naltrexone, and JAK Inhibitors

Conclusions

• Nail unit lichen planus is often diagnosed late because the inflammation is subtle, usually centered in the matrix, and nail bed biopsies can be falsely negative.
• Early treatment is important because scarring is irreversible and the main goal is to suppress inflammation before permanent nail damage occurs.
• Intralesional or systemic corticosteroids remain the first-line treatment, especially when disease is moderate to severe or involves multiple nails.
• Treatment response is slow and should generally not be judged before at least three months, with improvement ideally tracked by serial photographs and severity grading.
• Topical therapy has limited value for matrix disease, but clipping back onycholytic nail plate and treating nail bed involvement can improve topical delivery in selected mild cases.
• Low-dose naltrexone appears safe, well tolerated, and potentially effective for refractory nail lichen planus, though it often requires compounding and ongoing use.
• Systemic JAK inhibitors are promising for difficult cases and can produce marked improvement, but evidence is still limited and insurance coverage is a major barrier.
• Topical JAK inhibitors, especially compounded tofacitinib, showed encouraging results even in matrix-involved disease and may be an emerging option for mild isolated nail disease.
• Overall management should be individualized to the affected nail unit compartment and disease severity, with realistic expectations about incomplete response and recurrence.