Low-dose oral methotrexate versus oral prednisolone for eruptive lichen planus: A randomized comparative pilot study

Background: Eruptive lichen planus is a rare and severe variant characterised by widespread cutaneous involvement, intense pruritus, and frequent relapses. Systemic corticosteroids are commonly used but are associated with significant adverse effects and relapse. Low-dose methotrexate has emerged as a potential alternative.
Objectives: To compare the efficacy, safety, and relapse rates of oral prednisolone and oral low-dose methotrexate in eruptive lichen planus.
Methods: A randomized single-blind comparative pilot study was conducted among 30 patients attending the dermatology clinic at the National Hospital of Sri Lanka. Participants were allocated using computer-generated randomisation with allocation concealment via sealed envelopes. Patients received either oral prednisolone (0.5 mg/kg/day) or methotrexate (10–15 mg/week) for 16 weeks. Outcomes were assessed using the pruritus Numerical Rating Scale (0–10) and percentage body surface area (BSA) involvement. Intention-to-treat analysis was performed.
Results: Early partial response at 4 weeks was higher in the prednisolone group (66.7% vs 26.7%; p=0.028). At 16 weeks, complete response rates were comparable (86.7% vs 66.6%; p>0.05). Relapse at 6 months was higher in the steroid group (26.7% vs 6.7%). Adverse events were comparable.
Conclusions: Prednisolone provides faster disease control, while methotrexate may reduce relapse. Methotrexate is a safe and effective alternative.