Upadacitinib Treatment for Fulminant Cutaneous and Mucosal Lichen Planus

We report an otherwise healthy 24-year-old woman with a fulminant presentation of cutaneous and mucosal lichen planus (LP), progressing from approximately 15% to 80% total body surface area (BSA) in four weeks without an identifiable drug or infectious trigger. Oral examination was initially negative for signs of mucosal LP, such as Wickham striae and associated erosions. Subtle Wickham striae developed at the labial frenulum with mild sensitivity to spicy foods by week four. Laboratory evaluation, including complete blood count (CBC), comprehensive metabolic panel, antinuclear antibody, hepatitis panel, and human immunodeficiency virus testing, was unremarkable. Punch biopsy demonstrated hyperkeratosis, hypergranulosis, irregular acanthosis, and a vacuolar lichenoid interface dermatitis consistent with LP. The patient began treatment with clobetasol 0.05% cream applied to the affected areas of the wrists, elbows, knees, and feet as well as triamcinalone 0.1% cream applied to the affected areas of the back, chest, arms, and legs. Both medications were applied twice daily as needed for two weeks per month for one month total. As the patient was refractory to this treatment, the patient was treated with tacrolimus 0.1% ointment and ruxolitinib 1.5% cream twice daily for four weeks without adequate improvement, still reporting 10/10 pruritus. Disease was refractory to topical corticosteroids and subsequent topical anti-inflammatory therapy. Subsequently, she was started on systemic treatment with oral upadacitinib at a dose of 15 mg daily. Systemic treatment with upadacitinib led to rapid improvement with resolution of pruritus and regression of plaques within three weeks. After three weeks, plaques regressed and pruritus resolved (0/10). The patient described increased quality of life as a result of treatment. This case depicts a severe, rapidly progressive LP in a younger adult without comorbidities or risk factors. Similar presentations warrant early clinicopathologic confirmation and timely therapeutic escalation, including systemic options such as upadacitinib, to limit symptom progression and complications of extensive disease.