Updates in the Management of Lichen Planus Pigmentosus: A Narrative Review

Lichen planus pigmentosus (LPP) is a chronic, acquired dermal melanosis characterized by slate-gray to brownish-black macules and patches, predominantly affecting individuals with darker skin phototypes. The condition often involves photo-exposed and flexural sites and is associated with significant cosmetic and psychosocial distress. Etiopathogenesis is multifactorial, implicating T-cell–mediated interface dermatitis, ultraviolet and visible light exposure, and contact allergens such as para-phenylenediamine. Management is challenging due to its recalcitrant nature, limited high-quality evidence, and the risk of post-treatment pigmentary alterations. This narrative review synthesizes prospective and interventional studies evaluating current and emerging therapies for LPP. Topical calcineurin inhibitors, particularly tacrolimus 0.03% ointment, have shown moderate to excellent improvement in over half of treated patients without significant adverse effects. Low-dose oral isotretinoin (20 mg/day) demonstrated moderate to good improvement in approximately 78% of cases, with manageable side effects. Oral tranexamic acid (250 mg/day) provided partial improvement and sustained remission in compliant patients, emphasizing the need for thromboembolic risk assessment. Energy-based therapies, notably Q-switched Nd:YAG laser, offer targeted pigment reduction, with high-fluence protocols yielding faster clearance but greater side-effect risk, and low-fluence “laser toning” showing more gradual improvement with better tolerability. Platelet-rich plasma therapy achieved ≥50% clearance in 41.7% of patients in pilot studies, with minimal adverse events. Emerging data suggest Janus kinase (JAK) inhibitors, such as oral tofacitinib, may hold promise in refractory generalized cases. A pragmatic approach involves strict photoprotection, allergen avoidance, and patient counseling, followed by topical therapy for localized disease and systemic agents for extensive or progressive cases. Procedural and regenerative modalities may be considered for refractory disease in experienced hands. Larger randomized controlled trials, standardized outcome measures, and longer follow-up are required to establish optimal treatment protocols for LPP.