Abstract
Nail lichen planus (NLP) is a rare, chronic inflammatory nail disorder that can result in irreversible damage. While clinical awareness is growing, long-term real-world data-particularly incorporating histopathological confirmation and treatment outcomes-remains limited. We retrospectively analyzed 81 biopsy-confirmed NLP cases (2016-2024) from a Chinese dermatology center to characterize their epidemiological, clinical, histological features, treatment responses, and long-term outcomes. The mean age at onset of our cohort was 44.41 ± 17.77 years, with a slight male predominance (59.26%). Nail matrix involvement occurred in 97.53% of patients, and disease severity did not correlate with disease duration. Longitudinal biopsies showed a 96.30% concordance rate between clinical and histopathologic localization and revealed ventral proximal nail fold inflammation in 58.02% of patients. Patient satisfaction with the biopsy procedure was generally high (mean score: 8.32), though 14.52% reported dissatisfaction due to post-procedure deformity. Misdiagnosis occurred in 44.44% of patients. Among 62 patients with treatment follow-up, systemic corticosteroids were the most effective therapy, especially in those with periungual erythema; although 42.86% relapsed after discontinuation. JAK inhibitors demonstrated encouraging results in refractory cases. Oral acitretin showed moderate efficacy in early disease, while topical corticosteroids, calcineurin inhibitors, and hydroxychloroquine were largely ineffective. This study presents the largest long-term cohort of biopsy-confirmed NLP to date and offers new insights into its clinical spectrum, diagnostic strategies, and real-world treatment outcomes. It highlights the utility and limitations of longitudinal biopsy, the potential predictive value of periungual inflammation, and the emerging role of JAK inhibitors as promising therapeutic agents in recalcitrant cases.