Thalidomide is ineffective in the treatment of lichen planopilaris

To the Editor: George and Hsu1.George S.J. Hsu S. Lichen planopilaris treated with thalidomide.J Am Acad Dermatol. 2001; 45: 965-966Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar describe a 41-year-old white woman who presented with a patchy cicatricial alopecia of the scalp associated with lichen planus of the trunk and buccal mucosa. The scalp biopsy confirmed late-stage lichen planopilaris (LPP). The authors reported significant hair regrowth after one month's treatment with oral thalidomide, 150 mg in the evening, tapered to 50 mg for another month. The patient was then lost to follow-up, precluding any claim of long-term benefit. Thalidomide has been used to treat erosive lichen planus2.Dereure O. Basset-Seguin N. Guilhou J. Erosive lichen planus: Dramatic response to thalidomide.Arch Dermatol. 1996; 132: 1392-1393Crossref PubMed Google Scholar and chronic lupus erythematosus.3.Holm A.L. Bowers K.E. McMeekin T.O. Gaspari A.A. Chronic lupus erythmatosus treated with thalidomide.Arch Dermatol. 1993; 129: 1548-1550Crossref PubMed Scopus (42) Google Scholar We treated 6 patients (4 with LPP and 2 with pseudopelade of Brocq) with thalidomide in a 6-month open trial; and initial dose of 100 mg/day was given for the first month and then progressively increased, depending on response, up to 200 mg/day. Evaluation methods included standardized global photographs (Canfield Scientific), hair counts by macrophotographs (Dermaphot) of hair growth in a shaved area marked by a central tattoo, and investigator global assessment of hair growth. Patients were evaluated bimonthly for 6 months. End points were derived from investigator assessments of global photographs and hair counts. Global photographs at month 6 showed that 2 cases of LPP were worse and that 2 with pseudopelade of Brocq were unchanged; the last 2 with LPP were lost to follow-up at months 2 and 4, respectively, without any regrowth. None of the patients showed clinical improvement. Hair counts in macrophotographs at 6 months revealed an average 16% hair loss in the 4 patients who completed treatment. The hair loss in 2 patients with LPP who finished the 6-month treatment was evaluated at −40% and −5%, respectively. The hair loss in the other 2 patients with LPP lost to follow-up was evaluated at −11.1% and −12% after 2 and 4 months, respectively. A serious side effect of treatment was 1 case of sensory neuropathy, which slowly improved 12 months after stopping thalidomid. Thus, in our study, thalidomide was ineffective in treating LPP. In the case reported by George and Hsu, successful regrowth was claimed based on the investigator's interpretation of global photographs that were not standardized and, therefore, were not comparable. Also, no hair counts were made. The rapid regrowth of hair they reported must be highly unusual in such late-stage alopecia. It is difficult for us to conclude that oral thalidomide offers any benefit in the treatment of LPP; furthermore, its potential for serious side effects appears to offset any hypothetical potential benefits.