P2885 - Esophageal Lichen Planus Masquerading as Lymphocytic and Eosinophilic Esophagitis: Treatment Response to Tofacitinib

Award: ACG Presidential Poster Award

Evan Wilder, MD¹, Quan Nhu, MD, PhD²
1Scripps Clinic, San Diego, CA; 2Scripps Clinic & Scripps Research Institute, La Jolla, CA

Introduction: Lichen planus is a chronic, immune-mediated disorder that affects mucocutaneous sites including skin, mouth and esophagus. Esophageal lichen planus (ELP) is a rare, though increasingly emerging entity without standardized treatment. We describe herein the successful treatment of ELP with the Janus kinase (JAK) inhibitor tofacitinib.

Case Description/

Methods: A 53-year-old female presented with worsening GERD and dysphagia. EGD showed a narrow esophagus with white lacy friable mucosa. Esophageal biopsies showed 30 intraepithelial lymphocytes (IEL)/high-power field (hpf) with minimal eosinophils (5 eos)/hpf. Lymphocytic esophagitis (LyE) was diagnosed. LyE progressed despite high-dose PPI and oral viscous budesonide, requiring Savary dilation of the narrow-caliber esophagus to 30-Fr. Escalation to systemic steroid with prednisone 40 mg, while continuing high-dose PPI, failed to improve the working diagnosis of LyE. On high-dose esomeprazole and prednisone, EGD showed a diffusely narrowed 9-mm esophagus with diffuse patches of white lacy mucosa, multiple thick white linear exudates, edema, rings and strictures status post dilation. Esophageal biopsies showed prominent lymphocytosis but also 20 eos/hpf, making LyE now unlikely. Esophageal eosinophilia could suggest eosinophilic esophagitis (EoE) or the EoE-variant with lymphocytosis (Greuter et al., 2024). At this point, combining endoscopic and histologic findings, the thick white linear exudates, treatment refractory nature, review of esophageal biopsies revealed lichenoid esophagitis. Additional evaluation of persistent gingivitis unresponsive to steroids further supported the alternative diagnosis of ELP with oral involvement. Off label tofacitinib 5 mg twice daily was started. Gingivitis resolved within 1 month. Serial EGD’s demonstrated mucosal healing after 6 months on tofacitinib. Esophageal biopsies showed absent lymphocytosis with < 10 eos/hpf. Narrow-caliber esophagus responded to serial dilations.

Discussion: ELP is a rare but likely under-diagnosed disease. Treatment generally consists of immunosuppressive agents, however, is not standardized in part due to the overall rarity of the condition. Typical regimens include PPI and swallowed steroids initially, followed by systemic steroids and immunosuppressive agents. JAK inhibitors have shown promise in treating ELP in a few case reports. This case of ELP with response to tofacitinib adds to the encouraging literature on JAK inhibitors as a potential treatment option for patients with ELP.

Disclosures:
Evan Wilder indicated no relevant financial relationships.
Quan Nhu: Regeneron – Advisory Committee/Board Member, Consultant, Speakers Bureau. Sanofi – Advisory Committee/Board Member, Speakers Bureau. Takeda – Advisory Committee/Board Member, Speakers Bureau.

Evan Wilder, MD¹, Quan Nhu, MD, PhD². P2885 - Esophageal Lichen Planus Masquerading as Lymphocytic and Eosinophilic Esophagitis: Treatment Response to Tofacitinib, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.