At this time, no US-based guidelines for LP management exist, and only limited literature provides recommendations for screening [13, 14]. While historically linked to HCV, estimations of comorbidity prevalence in a retrospective monocentric study of 619 patients identified HTN in 45.40% and hypercholesterolemia in 36.83% of patients, followed by notably prevalent malignancy (19.06%), metabolic disorders (15.51%), type II DM (16.35%), depression (12.76%), thyroiditis (12.44), and rheumatic diseases (11.95%) [5]. Screening patterns in our cohort are not consistent with these findings. Among clinicians performing screening, screening rates for common comorbid conditions were strikingly low and deviated from current evidence of comorbidity prevalences. HCV and HBV are rare comorbidities in patients with LP, found in only 0.64% and 0.56%, respectively, in a study of 3.6 million individuals [15]. Based on the European S1 LP management guidelines, the association between LP and HCV is geographically dependent, with screening recommended only in regions with a high prevalence of HCV. Still, HCV and HBV were the most screened for comorbidities, with almost all respondents screening for HCV. HIV is not an established LP comorbidity; however, over a quarter of respondents performed HIV screening [9]. While a potential explanation for these trends may be the inclination to perform comprehensive blood-borne infection screening given LP’s association with HCV, these screening trends emphasize a misuse of resources in patients with LP without risk factors for hepatitis and/or HIV and ultimately opportunities for continued education.

DM and TDs are well-established comorbidities of oral LP (OLP), with estimated prevalences of 1.6–37.7% and 30–50% of patients with OLP, respectively [16, 17]. While DM and TDs were the third and fourth most commonly screened for comorbidities in this cohort, respectively, they were still only screened for by one-third of the respondents performing screening. These gaps in evidence-based screening practices may reflect OLP’s infrequent presentation among patients treated by practitioners in this cohort, compounded by knowledge gaps.

Screening for depression, anxiety, HTN, and dyslipidemia showcase additional missed opportunities for the dermatologist to appropriately identify and manage comorbidities. Depression and anxiety have been reported to be present in as many as 42% and 44% of patients with LP, respectively, though screening for these psychological comorbidities was disproportionately low by this cohort [7, 14]. Similarly, only 10% of respondents screened for HTN and dyslipidemia despite their reported prevalence of up to 45% and 37% in patients with LP, respectively [5]. European S1 guidelines explicitly recommend lipid screening in patients with LP to identify those at risk for cardiovascular disease [9].

Gaps in comorbidity screening by dermatologists extend beyond LP. In one survey study, less than 20% of 73 dermatologists screened for systemic conditions associated with rosacea despite strong evidence of its association with HTN, dyslipidemia, DM, anxiety, and depression [18]. Similar underestimations of depression and anxiety were observed in a cross-sectional analysis of 3635 dermatology consultations in Europe, particularly among patients with hand eczema, psoriasis, and leg ulcers [19]. Large-scale US studies have demonstrated depression screening in only 2% of patients with hidradenitis suppurativa (HS) despite their frequent coexistence and suboptimal cardiovascular screening in patients with psoriasis, HS, and atopic dermatitis [20, 21].

Importantly, despite the numerous well-established associations between LP and comorbid conditions, 32.5% of our surveyed cohort performed no screening at all. Though targeted screening should be based on a patient’s individual risk factors and presentation, almost one-third of this cohort entirely foregoing screening underscores a large gap in the holistic management of patients with LP. Additionally, increased screening likelihood by attending physicians highlights the potential role of advanced training and experience in influencing clinical decision-making, whereas other demographics and practice location appeared to play a lesser role in this context. Over half of attending physicians responding to the survey were ages 30–39; thus, the lack of association between screening and practitioner age suggests that clinical habits formed during training are more valuable in holistic LP management than the time spent in practice.

Clinicians of all levels would undoubtedly benefit from screening guidelines. Though European S1 guidelines for LP management are available, they were most recently released in 2020 and do not include more recently identified comorbidities [9]. Comorbidity screening guidelines for patients with LP could help close the screening gap, ensure that screening practices are on par with current evidence, and, most importantly, prevent comorbid conditions in patients with LP from remaining undiagnosed and untreated.

Regarding management of LP, TCSs are a central component of treatment, their use supported by level I evidence for treatment of cutaneous, oral, and scalp LP and European S1 guidelines for cutaneous and mucosal LP [9, 11, 14]. TCSs are mainstays in treating inflammatory dermatologic conditions, making their first-line placement in treating LP unsurprising [22]. The commonplace use of TCSs by this cohort for LP treatment mirrors the findings of a recent cross-sectional study of 1998 patients and a retrospective study of over three million patients in which TCSs were the most used treatment, prescribed to 38–48% of patients [4, 15].

TCIs were the second-most utilized treatment option in this cohort, with class IA and IB evidence supporting their use in cutaneous and OLP [11]. While some literature regards TCIs as a first-choice therapy equal to TCSs for OLP, TCIs are a second-line recommendation for cutaneous LP in the European S1 guidelines [9, 22]. ILCSs were the third most utilized treatment in this cohort, aligning with level I evidence on their efficacy in scalp LP as well as recommended use for cutaneous LP by European S1 guidelines [9, 11].

While European S1 guidelines and recommendations align with the popularity of OIs in this cohort, differing levels of evidence exist for the use of these agents. Interestingly, patterns in OI prescribing in this study cohort mirrored levels of evidence supporting their use. Methotrexate has class IIB evidence for use in cutaneous LP, aligning with its leading position among OIs, while azathioprine, the least frequently used OI, has only class IV evidence. Cyclosporine and mycophenolate mofetil have class III evidence for use in scalp LP and OLP, respectively, calling into question their frequent use despite low-quality evidence and significant side effect profiles [11].

Other treatments with class I evidence and recommendations for use by European S1 guidelines, including acitretin and isotretinoin for cutaneous and mucosal LP and phototherapy for cutaneous LP, were less frequently used in this cohort. Sulfasalazine and griseofulvin, used by only 3.0% and 0.5% of respondents, respectively, also have high-level evidence (level IB) for cutaneous LP [9, 11]. Less frequent use of systemic retinoids may be limited by barriers to prescribing these agents. Insight into the limited use of phototherapy by this cohort was provided in respondents’ comments, which detailed difficulties in obtaining insurance coverage for treatment and/or limited availability of phototherapy in their practice.

Varied use of agents with high-level evidence in cutaneous LP may be reflective of cutaneous LP’s self-limited nature and relatively benign course, allowing for treatment deferment [9]. Additionally, only 4.2% of this cohort had a majority of patients presenting with severe LP. Among practitioners who care for more patients experiencing severe and/or recalcitrant OLP, the use of evidence-based treatments like oral retinoids may be warranted considering treatment challenges faced with OLP, effects on patients’ quality of life, and potential malignant sequelae [13, 14].

For scalp and nail LP, TCSs, TCIs, ILCSs, systemic steroids, cyclosporine, hydroxychloroquine, and methotrexate are recommended by the European S1 guidelines. First-line treatment of isolated nail LP with ILCSs and intramuscular corticosteroids (IMCSs), specifically triamcinolone, is also recommended by an expert consensus of international dermatologists, with oral retinoids and OIs recommended as second-line agents [9, 23]. These recommendations align with this cohort’s prescribing patterns, apart from hydroxychloroquine which was prescribed by less than 2% of respondents. Notably, however, nail LP was the least common variant treated by respondents.

The advent of newer treatment modalities for LP and their mounting evidence for use is reflected in the cohort’s prescribing patterns. As the JAK/signal transducer and activator of transcription (STAT) pathway is believed to be implicated in the pathogenesis of LP, JAKis have proven useful in the treatment of all forms of LP. Another mechanism for targeting inflammation in LP has been through the use of phosphodiesterase 4 (PDE4) inhibitors, specifically apremilast, used most often in recalcitrant OLP. Additionally, targeting the IL-23/IL-17 pathway involved in LP through mAbs antagonizing these cytokines have proven useful [2]. The use of JAKis, PDE4 inhibitors, and mAbs by this cohort mirrors awareness of their utility in treating LP; however, the cohort’s predilection for older mAbs, specifically anti-TNF agents, may reflect less up-to-date treatment practices.

The use of combination therapies in LP may draw from their success in the treatment of other dermatologic conditions [24, 25]. Through combining agents that modulate the immune response and inflammation, TCSs, TCIs, and retinoids may work synergistically or additively while simultaneously minimizing side effects. Of note, all the most common combination regimens included TCSs [24]. A similar immune-modulating mechanism can be postulated for the use of low-dose tetracyclines, phototherapy, and OIs [11]. Additionally, evidence of phototherapy’s superiority to systemic steroids in cases of severe, recalcitrant, cutaneous LP refractory to TCS and OIs may speak to their prevalence in combination therapies [11, 14, 22].

The interplay of treatment choice and a respondent’s demographic background was noteworthy, as older clinicians, physicians, and those in academic or group practice settings were more likely to prescribe systemic treatments. Tailored educational strategies and prescribing guidelines could address treatment variations to ensure evidence-based prescribing across demographics and practice settings.

While multiple treatment modalities have proven useful in the treatment of LP, none are FDA-approved for use in LP. Over one-quarter (25.6%) of respondents in this cohort believed that there are FDA-approved medications for LP, exemplifying a notable knowledge gap.

While this misconception may in part be due to the commonplace use of certain treatments for LP, like TCSs and TCIs, this data highlights an opportunity for continued education for clinicians, especially resident physicians, to best inform decision-making when presenting treatment options to patients.

Given the generalized questions included in this survey design, the ability to capture the nuance of treatment choices for individualized patient cases is limited. Seeking further insight into respondents’ treatment algorithms for specific LP subtypes could provide greater clarity on the nuance of treatment options, as well as inform development of future guidelines. The use of gift cards as incentives for the first 200 respondents may have potentially influenced participation. Additionally, while it was requested of respondents to answer questions on the basis of their knowledge at the time of responding, the anonymous and email-based distribution may have allowed for respondents to reference educational materials and sources while completing the survey. Lastly, while prescribing privileges do not fundamentally differ between different dermatology practitioners based on their level of specialization, factors such as institutional limitations for trainees, variations in patient payer mix, and greater willingness among academic dermatologists to use off-label therapies may have influenced treatment practices but were not specifically accounted for in this analysis.