How do you approach treating nail lichen planus?

I would first start be determining the extent of cutaneous and mucosal involvement, as that often is more troublesome to the patient than the nails and may impact choice of treatment. Often, any systemic therapy directed at cutaneous/mucosal LP will also probably improve nail LP. Topical steroids to...

I generally start with IM kenalog bridge with Hydroxychloroquine to start.

Based on response/lack of response, then move to either Acitretin or MTX as Dr. @Dr. First Last mentions, and IM kenalog pulse dose bridge, particularly for MTX.

Acitretin works fairly quickly, and I have sometimes had success ...