Esophageal Lichen Planus: The Efficacy and Safety of Tacrolimus in Reducing Inflammation and Need for Dilation.

Introduction: Esophageal lichen planus (ELP) is a rare inflammatory disease most seen in middle-aged White women, manifested by sloughing mucosa, thick exudate, and proximal strictures. Most case reports and small series highlight using steroids and other immunosuppressants. To the best of our knowledge, oral tablet tacrolimus has not been studied. We aimed to assess the change in ELP after oral tacrolimus treatment.

Methods: The primary outcome was the efficacy of tacrolimus objectively through our scoring system, ELP Severity Score (ELPSS). All consecutive adults with ELP who underwent more than one esophagogastroduodenoscopy by 2 esophagologists and being treated with tacrolimus or other treatment were eligible for inclusion in this retrospective cohort study. Inflammation and fibrostenotic disease were graded using the novel ELPSS.

Results: Twenty-two patients met the inclusion criteria. Half (11) received tacrolimus (dose 1-2 mg twice daily), and half (11) received other therapy (i.e., cyclosporine, topical steroids, or none). Mean ELPSS on the first esophagogastroduodenoscopy, extraesophageal manifestations of disease, presenting symptoms, and baseline characteristics were similar between groups. Among patients on Tac vs No-Tac, there was a statistically significant improvement in ELPSS (mean difference 1.8 pts; 95% confidence interval 0.25-3.38; P = 0.02). Response rate was 89% with Tac vs 30% with No-Tac ( P = 0.025). All 22 patients underwent bougie dilation safely with a mean diameter of 16 mm achieved. Patients on Tac also required less frequent dilation.

Discussion: Oral tablet tacrolimus reduced the inflammatory and fibrostenotic components of ELP. Thus, low-dose oral tacrolimus is safe and should be considered in patients with more severe disease.