Use of Etanercept in the Treatment of Moderate to Severe Lichen Planus

The purpose is to assess the response of subjects to etanercept (as compared to placebo) in treating the physical signs of mucosal and cutaneous lichen planus. The investigators also wish to assess the effect of etanercept on disease-related itching, pain, and serious adverse events in patients with lichen planus.

Lichen planus affects up to 1% of the worldwide population. Recent estimates suggest approximately 0.44% of the US population suffers from this disease. Oral or genital involvement occurs in 60-70% of patients, and it may be the sole manifestation of disease in 20-30% of patients.

Lichen planus is a mucocutaneous disorder that can involve the skin, oral or genital mucosa, conjunctiva, and nails. On the skin, the disease presents as multiple papules, which can be localized or generalized, that are often extremely itchy. Mucosal disease can consist of either asymptomatic plaques or extremely painful erosive lesions. The disease course is unpredictable and typically lasts 1-2 years but can follow a chronic, relapsing course. Erosive mucosal disease is important to aggressively treat for many reasons: First, the associated pain can be debilitating for the patient. Patients with severe oral lichen planus can become malnourished due to pain associated with eating. Vulvar disease can cause dyspareunia, burning pain, and discharge; second, the disease tends to be chronic, with little chance for self-resolution; third, erosive disease is associated with an increased risk of squamous cell carcinoma in the affected areas. These cancers occur in up to 1% of patients over a 3-year period, and they can be aggressive and even-life threatening for the patient if not recognized and treated early.

Several lines of evidence suggest that TNF-alpha plays a role in the pathogenesis of lichen planus. It has been shown that there are increased levels of TNF-alpha in the serum of these patients. In addition, skin and mucosal biopsies show increased TNF-alpha produced by the infiltrating lymphocytes as well as the basal keratinocytes. It has been suggested that the expression of TNF-alpha receptor on the basal keratinocytes may contribute to apoptosis. Also, TNFR1 (a TNF-alpha receptor) is expressed by the infiltrating mononuclear cells as well as the keratinocytes. Increased levels of soluble TNF receptors are also found in the serum of patients with lichen planus. A recent report also has shown that polymorphisms in the TNF-alpha gene are associated with both oral and cutaneous lichen planus. Finally, thalidomide, which partly functions as a potent inhibitor of TNF-alpha transcription, has been shown to be effective (in small case series and reports) in selected patients for the treatment of oral and genital lichen planus. However, thalidomide is a potent teratogen and cannot be used in women of childbearing potential. In addition, thalidomide usage not uncommonly results in neurotoxicity, which can be permanent, and thus limits use of this drug. Despite the evidence for a role of TNF-alpha in LP there are no reports of any TNF inhibitors being used for this disease.

This is a double-blind, placebo-controlled pilot study to observe the safety and efficacy of etanercept in patients with lichen planus.

This study will consist of 3 periods: first, a double-blind period (weeks 0-12) in which subjects will be randomized to etanercept 50 mg twice weekly or placebo; second, an open-label period (weeks 12-24) in which subjects who were randomized to placebo treatment, who have not achieved a complete remission, will be rolled over to use etanercept at 50 mg twice weekly. Subjects who previously received etanercept during weeks 0-12, who have not achieved a complete remission, will be continued on etanercept at a lower dosage of 25 mg twice weekly for weeks 12-24; third, an 8 week follow-up period for all subjects.

Eligibility Criteria:
Inclusion Criteria:

* At least 18 years old.
* Must carry a diagnosis of lichen planus as determined by biopsy
* Patients must have a score of 3 or greater on the physician global assessment (PGA).
* Patient must be considered appropriate for systemic therapy based upon fulfilling one of the following criteria:

  1. inability to maintain weight due to pain with eating, chewing, or swallowing;
  2. dyspareunia or dysuria due to genital lesions;
  3. itch/pain of sufficient severity that activities of daily living are significantly affected
* Must be off systemic lichen planus treatment for 4 weeks prior to starting etanercept
* If using topical corticosteroid to the affected areas, the dose and frequency must be unchanged for 2 weeks prior to beginning the study agent and during the course of the study.
* Must be off topical cyclosporine, tacrolimus, or pimecrolimus for 2 weeks prior to starting the study drug and for the entire duration of the study.
* Must be able and willing to give written informed consent and comply with the requirements of the study protocol and must authorize release and use of protected health information.
* Women of childbearing potential must have a negative pregnancy test at the time of entry into the study and must be practicing successful contraception for at least 3 months prior to the study.
* Subject or designee must have the ability to self-inject investigational product.
* Screening laboratory results are within the following parameters:

  * Hemoglobin \> 10 g/dL
  * White blood cells \> 3.5 x 10\^9/L
  * Neutrophils \> 1.5 x 10\^9/L
  * Platelets \> 100 x 10\^9/L
  * Lymphocytes \> 0.5 x 10\^9/L
  * Serum creatinine \< 1.5 mg/dL
  * Hepatitis C serology - nonreactive
  * AST and ALT \< 2X upper limit of normal (ULN)

Exclusion Criteria:

* Subject is currently enrolled in another investigational device or drug trial(s), or subject has received investigational agent(s) within 90 days of baseline visit.
* Known HIV-positive status, any other immuno-suppressive disease, or inability to practice safe sex during the length of the study
* Subject has been diagnosed with a malignancy within the past 5 years
* Subject has signs or symptoms of a lymphoproliferative disease.
* Other skin or mucosal disease that might interfere with lichen planus assessments.
* Lichen planus variants including hypertrophic, atrophic, follicular (including lichen planopilaris), and bullous cutaneous forms.
* Patients with lichen sclerosis et atrophicus (LS\&A)
* Clinical history and lesion distribution suspicious for a lichenoid drug eruption
* Severe co-morbidities
* History of tuberculosis (TB) or positive PPD at screening. Known history of active hepatitis B or C, or lupus, SLE, history of multiple sclerosis or prior episode of central nervous system demyelination, transverse myelitis, optic neuritis, epilepsy, psychiatric condition, or other chronic serious medical illnesses.
* Subject has a diagnosis of congestive heart failure (CHF) of any severity
* Use of a live vaccine 90 days prior to, or during this study.
* Previous exposure and/or known sensitivity to etanercept
* Concurrent use, or failure of, any TNF-inhibitor
* Previous exposure to alefacept or efalizumab within 6 weeks of administration of study drug
* Concurrent sulfasalazine therapy
* Prior or concurrent cyclophosphamide therapy
* Active severe infections, or prior infection requiring hospitalization or oral/intravenous antibiotics within 4 weeks before screening visit, or between the screening and baseline visits.
* Active inflammatory bowel disease or peptic ulcer disease
* Drug or alcohol abuse within 12 months of screening visit.
* History of non-compliance with other therapies
* Pregnant or lactating
* Documented presence of any of the following:

  * Proteinuria \> 1+ by dipstick screening
  * 24 Hour protein excretion \> 0.5 g
  * Symptomatic liver disease with serum albumin \< 3 G/DL
  * PT or PTT \> ULN, or
  * Chronic liver disease
* Documented forced vital capacity \< 50% of predicted