Desquamative gingivitis: early presenting symptom of mucocutaneous disease

Desquamation of the gingiva is a sign that may be encountered in clinical practice. Various diseases can affect the gingival tissues. Mild desquamation that is localized may be associated with mechanical irritation or induced by trauma. Moderate to severe generalized desquamation associated with ulceration and erythema may be indicative of a more serious systemic condition. Although often overlooked, mucocutaneous diseases frequently present with gingival desquamation as an early presenting symptom. The most common mucocutaneous diseases that affect the oral cavity are lichen planus, pemphigus, and mucous membrane pemphigoid. This article reviews the etiology, signs and symptoms, and therapies for these disorders. Increased knowledge of mucocutaneous diseases can help the clinician recognize these disorders and enable the patient to receive appropriate therapy.

Long-term efficacy and safety of topical tacrolimus in the management of ulcerative/erosive oral lichen planus

The long-term safety and clinical benefit of topical tacrolimus for the management of erosive or ulcerative oral lichen planus has not been evaluated. 50 adults (39 female 11 male; group median age 59, range 29-88 years) with symptomatic, erosive or ulcerative lichen planus recalcitrant to topical corticosteroids applied 0.1% topical tacrolimus ointment twice daily to symptomatic mucosal lesions. Topical tacrolimus was applied for a median time of 19.8 months (range 2-39 months) in this patient group. Fourteen percent of the patients had complete resolution of ulcers or erosions, 80% partial resolution and 6% reported no clinical benefit. The most common adverse effects were a burning sensation (16%) at the site of application and transient taste disturbance (8%). No significant, long-standing changes in hepatic or renal biochemistry were observed. The mean tacrolimus level decreased with duration of therapy from 2.7 microg/l (week 1) to 0.5 microg/l (week 32). 0.1% topical tacrolimus is an effective means of controlling the symptoms and signs of erosive or ulcerative oral lichen planus and has no notable adverse effects over a mean duration of application of 19.8 months.

Clinical evaluation in treatment of oral lichen planus with topical fluocinolone acetonide: a 2-year follow-up

BACKGROUND

Oral lichen planus (OLP) is a chronic inflammatory disease which is recalcitrant to medical treatment. The purpose of this study was to compare the effectiveness of various forms of the topical steroid fluocinolone acetonide applications in patients with OLP.

METHODS

Data of OLP patients were collected retrospectively from the chart record and the 97 OLP patients were divided into three groups. The first group (n = 28) was treated with a 0.1% solution of fluocinolone acetonide (FAS), the second group (n = 22) with 0.1% fluocinolone acetonide in orabase (FAO), and the third group (n = 47) with both FAS and FAO (FAS/FAO) throughout the study. Each group was clinically evaluated as complete remission (CR), partial remission (PR), or no response (NR), following the treatment. Also, the side-effect of oral candidiasis was recorded in each group.

RESULTS

Two years of treatment resulted in complete remission of 77.3, 21.4, and 17.0% of patients in the FAO, FAS, and FAS/FAO groups, respectively. There was a statistically significant difference in disease remission (P < 0.05), but not in oral candidiasis appearance (P > 0.05) among various forms of topical steroid application.

CONCLUSION

The study concluded that FAO or FAS can produce improved results in the management of OLP by long-term follow-up.

Systemic and topical corticosteroid treatment of oral lichen planus: a comparative study with long-term follow-up

BACKGROUND

Topical corticosteroids are the mainstay treatment for oral lichen planus (OLP), but some authors suggest that systemic corticosteroid therapy is the only way to control acute presentation of OLP.

METHODS

Forty-nine patients with histologically proven atrophic-erosive OLP were divided into two groups matched for age and sex. The test group (26 patients) was treated systemically with prednisone (50 mg/day), and afterwards with clobetasol ointment in an adhesive medium plus antimicotics, whereas the control group (23 patients) was only treated topically with clobetasol plus antimycotics.

RESULTS

Complete remission of signs was obtained in 68.2% of the test group and 69.6% of the control group, respectively (P = 0.94). Similar results were obtained for symptoms. Follow-up showed no significant differences between the two groups. One-third of the patients of the test group versus none in the control group experienced systemic side-effects (P = 0.003).

CONCLUSIONS

The most suitable corticosteroid therapy in the management of OLP is the topical therapy, which is easier and more cost-effective than the systemic therapy followed by topical therapy.

Oral lichen planus: progress in understanding its malignant potential and the implications for clinical management

Oral lichen planus (OLP) is an inflammatory lesion that has malignant potential, but few cases of OLP progress to malignancy. A diagnosis of OLP should be confirmed on the basis of historical, clinical, and histologic data. The presence of dysplasia in an OLP-like lesion increases the risk of malignant transformation, mandating management and close follow-up. A molecular assessment of OLP may provide the best evidence of malignant risk and will likely become available for clinical use. In addition, exfoliated cells may be examined for loss of heterozygosity and may become a valuable clinical tool for patient follow-up. The treatment of OLP should include elimination of tissue irritants and recurring exposure to oral carcinogens. If OLP is symptomatic, appropriate treatment with immunosuppressive medications, particularly corticosteroids, should be undertaken. For lesions with dysplastic changes, management may include attention directed to the inflammatory change and follow-up biopsies to assess residual histologic changes that may represent dysplasia. Dysplastic OLP may be best treated as other oral dysplastic conditions; thus, regular, more frequent follow-up is required.

Oral diseases possibly associated with hepatitis C virus

Morbidity associated with hepatitis C virus (HCV) infection can involve a variety of extrahepatic conditions, including lichen planus (LP) and sialadenitis, predominantly or exclusively involving the oral region, conditions which have been largely neglected in reviews. The literature suggests that HCV-infected patients may frequently have Sjögren-like sialadenitis with mild clinical symptoms, whereas oral LP may be significantly associated with HCV infections in Southern Europe and Japan but not in Northern Europe. These geographical differences could be related to immunogenetic factors such as the HLA-DR6 allele, significantly expressed in Italian patients with OLP and HCV. Analysis of experimental data suggests that HCV could be involved in the pathogenesis of both these diseases. Moreover, parotid lymphoma may arise in patients with sialadenitis, mainly with type II cryoglobulinemia. Little attention has been paid to oral health needs in HCV-infected patients and the variable effect of interferon-alpha therapy on oral tissues. Further research is needed, because of the potentially great influence of oral diseases possibly linked to HCV on the quality of life of millions of patients.

Treatment of severe erosive gingival lesions by topical application of clobetasol propionate in custom trays

OBJECTIVE

We sought to describe the response of patients with severe erosive gingival lesions to treatment with clobetasol propionate in Orabase paste administered in trays. The adverse effects were also recorded.

STUDY DESIGN

A descriptive pretest/posttest clinical study with no control group (33 patients total) was developed. All patients received repeated applications of 0.05% clobetasol propionate plus 100,000 IU/cc of nystatin in Orabase paste. Over the 48-week period, the pain levels, ulcerations, presence of atrophy, and the patients' daily activities were recorded, and Likert scales were used to classify each outcome as either a complete recovery, excellent, good, poor, or failed. The presence of any adverse effect was also noted.

RESULTS

At the end of the study period, the pain and ulceration had disappeared (complete response) in 100% of the sample (33/33; 95% confidence interval = 89.4%-100%), and there was a complete recovery of daily activities and remission of atrophy in 93.9% (31/33; 95% confidence interval = 79.8%-99.3%) and 21.2% (7/33; 95% confidence interval = 9.0%-38.9%) of the patients, respectively. No adverse effects related to the treatment were observed.

CONCLUSIONS

The application of an Orabase paste of 0.05% clobetasol 17-propionate plus 100,000 IU/cc of nystatin by means of a tray appears to be an efficacious treatment for severe erosive gingival lesions.

Patient-centred outcome measures for oral mucosal disease are sensitive to treatment

The aim of this study was to evaluate the sensitivity of two patient-centred outcome measures to the topical application of a corticosteroid (betamethasone) in the treatment of oral lichen planus (OLP). Forty-eight patients with clinical and histological features of OLP were recruited to take part in a 6-week study of the effectiveness of topical betamethasone for the treatment of symptomatic OLP. Participants completed a questionnaire incorporating the 16-item UK Oral Health Related Quality Of Life measure (OHQOL) and the 14-item Oral Health Impact Profile (OHIP-14), rated their pain on 'global' and visual analogue scales (VAS) and underwent an oral examination, at the start and end of the trial. Four (8\%) patients failed to complete the study. The clinical signs of OLP had improved for half (22) of the patients following treatment. Twenty-nine (66%) reported that their oral pain had reduced ('global' scale). More objectively, there were significant differences in VAS ratings of pain (P =0.005), OHIP-14 scores (P =0.036) and OHQOL scores (P =0.003) between the start and end of the trial. In conclusion, both OHQOL and OHIP-14, patient-centred outcome measures are sensitive to the clinical effects of topical betamethasone in the treatment of oral lichen planus.

Oral lichen planus. Update for the general practitioner

There are a variety of dermatologic disorders that commonly present in the oral cavity. Among these is lichen planus which may affect the oral mucous membranes. Dentists need to be familiar with the clinical presentations of this disease. This article will review the common signs and symptoms of oral lichen planus, and will discuss the tools and criteria used to diagnose this disorder. We will also described the modalities available to clinicians to treat this disease.

Oral erosive/ulcerative lichen planus: preliminary findings in an open trial of sulodexide compared with cyclosporine (ciclosporin) therapy

OBJECTIVE

To study the effect of the heparinoid sulodexide systemically, compared with topical cyclosporine (ciclosporin), on chronic oral erosive/ulcerative lichen planus.

STUDY DESIGN

An open nonrandomized trial was conducted in two groups of 10 Italian patients with lichen planus, with subjective assessment of pain and assessment of ulceration amelioration by nonblinded clinicians.

RESULTS

Comparable pain relief and amelioration of erosions/ulcers were seen in patients on sulodexide and in those on ciclosporin, but with faster healing in those on sulodexide.

CONCLUSIONS

Sulodexide appears to be as effective, and perhaps more effective, than topical ciclosporin in the therapy of oral lichen planus, and is less expensive, but full double-blind placebo-controlled studies are required.

Peripheral sensory neuropathy associated with short-term oral acitretin therapy

A 57-year-old female patient with widespread chronic plaque psoriasis and a 32-year-old male patient with severe oral lichen planus are reported, who developed sensory symptoms in the extremities 3 and 4 months after the onset of oral acitretin therapy, respectively. Both patients showed clinical and electrophysiological evidence of a sensory peripheral neuropathy, which completely resolved 2 and 2.5 years after discontinuation of oral acitretin administration, respectively.

[Electrokinetic activity of the buccal mucosa epitheliocytes in patients with lichen planus]

The electrokinetic activity of buccal epithelial cells drops in patients with lichen planus. The most pronounced changes develop in patients with severe forms of the disease (exudative hyperemic and erosive ulcerative). The functional activity of the epithelium does not depend on sex or presence of metal dentures; the effect of the disease duration is negligible, while the underlying somatic disease is significant. The electrokinetic activity of epithelial cells is sharply reduced in cardiovascular patients with lichen planus of the buccal mucosa. Increase of electrokinetic activity of epitheliocytes after local drug therapy for lichen planus clinically manifests by epithelialization of erosions, which recommends this test for predicting the course and outcome of lichen planus.

Oral lichen planus: causes, diagnosis and management

Oral lichen planus (OLP) is a chronic inflammatory disease of unknown etiology. In this paper we review the clinical and histological features of OLP, process of OLP diagnosis, causes of OLP, management of OLP patients and medical treatment of OLP lesions. Approximately 0.2 per cent OLP patients develop intra-oral carcinoma each year compared with approximately 0.005 per cent Australian adults. Possible mechanisms of increased oral cancer risk in OLP patients are presented. The aims of current OLP therapy are to eliminate mucosal erythema and ulceration, alleviate symptoms and reduce the risk of oral cancer. Patient education may improve the outcomes of OLP therapy and further reduce the risk of oral cancer in OLP patients. Although OLP may be diagnosed clinically, appropriate specialist referral is required for: (i) histological diagnosis; (ii) assessment of causative/exacerbating factors, associated diseases and oral cancer risk; (iii) patient education and management; (iv) medical treatment; and (v) long-term review and re-biopsy as required.

Oral lichen planus: a preliminary clinical study on treatment with tazarotene

OBJECTIVE

The rationale for using tazarotene in oral lichen planus (OLP) is its regulatory action on the growth and differentiation of keratinocytes and on inflammation. This randomized, placebo-controlled study addresses evaluation of the effects of topic tazarotene in the treatment of OLP.

DESIGN

The degree of lesions before and after treatment scored by a 6-score scale in six cases treated with tazarotene was statistically compared with those of six controls treated with placebo.

SUBJECTS

Twelve patients with hyperkeratosic OLP were randomly allocated to treatment with tazarotene gel 0.1% b.i.d. or with placebo for eight consecutive weeks.

METHODS

The statistical comparison was executed by means of Wilcoxon analysis for paired data.

RESULTS

Patients treated with tazarotene presented a significant reduction of their lesions as compared with the control group. Among transitory side-effects, burning sensation and taste abnormalities were observed.

CONCLUSION

Topical tazarotene may be a valuable therapeutic tool in the treatment of hyperkeratotic OLP.

An open trial of topical tacrolimus for erosive oral lichen planus

Erosive oral lichen planus is a chronic, painful disease that is frequently refractory to treatment. We describe 6 patients with erosive oral lichen planus, not responsive to topical steroids, who showed substantial improvement with the use of topical tacrolimus ointment 0.1%. This medication was well tolerated and appears to be effective in controlling erosive oral lichen planus.

Treatment of chronic erosive oral lichen planus with low concentrations of topical tacrolimus: an open prospective study

BACKGROUND

Chronic erosive oral lichen planus (EOLP) is a severe form of lichen of the buccal mucosa that is often resistant to systemic or topical therapies.

OBJECTIVE

To evaluate the efficacy and safety of topical tacrolimus, 0.1 mg per 100 mL of water, in treating EOLP.

DESIGN

Open-label, prospective, noncomparative study, with 6 months of treatment and 6 months of follow-up.

SETTING

Dermatology department at a university hospital in Nice, France.

PATIENTS

Ten patients with histologically proved EOLP that was refractory to treatment. Two patients were withdrawn because of noncompliance; findings in 8 were available for evaluation.

INTERVENTIONS

Mouthwashes with tacrolimus, 0.1 mg per 100 mL of distilled water, 4 times daily for 6 months.

MAIN OUTCOME MEASURES

Efficacy was assessed using a calculated score that combined the intensity of spontaneous and meal-triggered pain and the surface area of erosions. Safety assessment included the monitoring of adverse effects, clinical laboratory values, and blood concentrations of tacrolimus.

RESULTS

Among the 8 patients evaluated, 1 had no improvement and 7 were improved. The mean score decreased from 7.00 at baseline to 5.43 (a 22.43% decrease) at 1 month, 4.14 (a 40.86% decrease) at 2 months, 3.00 (a 57.14% decrease) at 3 months, 2.43 (a 65.29% decrease) at 4 months, 2.57 (a 63.29% decrease) at 5 months, and 3.43 (a 51.00% decrease) at 6 months. A decrease of symptoms was reported by the 7 responding patients as soon as the first month of treatment. No severe adverse effects were observed. All patients had whole-blood concentrations of tacrolimus below the detection limit of the assay (1.5 ng/mL) at all intervals. At 9 months, 6 patients had had a relapse within a mean of 38.6 days. At 12 months, all patients had had a relapse and required treatment with topical corticosteroids or systemic hydroxychloroquine sulfate.

CONCLUSION

Results of our study suggest a rapid and important palliating effect of low concentration of topical tacrolimus in distilled water in patients with EOLP.

Oral lichen planus: clinical presentation and management

Oral lichen planus (OLP) is a chronic mucosal condition commonly encountered in clinical dental practice. Lichen planus is believed to represent an abnormal immune response in which epithelial cells are recognized as foreign, secondary to changes in the antigenicity of the cell surface. It has various oral manifestations, the reticular form being the most common. The erosive and atrophic forms of OLP are less common, yet are most likely to cause symptoms. Topical corticosteroids constitute the mainstay of treatment for symptomatic lesions of OLP. Recalcitrant lesions can be treated with systemic steroids or other systemic medications. However, there is only weak evidence that these treatments are superior to placebo. Given reports of a slightly greater risk of squamous cell carcinoma developing in areas of erosive OLP, it is important for clinicians to maintain a high index of suspicion for all intraoral lichenoid lesions. Periodic follow-up of all patients with OLP is recommended.

Fluticasone propionate spray and betamethasone sodium phosphate mouthrinse: a randomized crossover study for the treatment of symptomatic oral lichen planus

BACKGROUND

Symptomatic oral lichen planus (OLP) has been palliated with a wide spectrum of topical and systemic therapies. Although the majority of management strategies include corticosteroids, few have been evaluated in randomized controlled trials.

OBJECTIVE

We investigated the acceptability and efficacy of topical fluticasone propionate spray (FP) and betamethasone sodium phosphate mouthrinse (BSP) upon the signs and symptoms of OLP, assessing patient quality of life changes as a consequence of these therapies.

METHODS

We implemented a randomized, crossover study in which each drug was administered for a period of 6 weeks with an intervening washout period of 2 weeks at an outpatient oral medicine unit in London, United Kingdom. We treated 48 patients with biopsy-proven symptomatic OLP, and 44 patients (92%) completed the study. The dosage was 50 microg two dose unit sprays and BSP 500 microg, each 4 times daily. Symptomatic improvement was evaluated by means of a visual analogue scale (VAS), the McGill pain score, the Oral Health Impact Profile (OHIP), and Oral Health Quality of Life (OHQoL) questionnaires. The total surface area of the lesions, including all white, erythematous, and ulcerative lesions was measured at each visit. The efficacy, ease of application, and adverse effects associated with each medication were recorded.

RESULTS

Both FP and BSP mouthwash caused both a statistically significant reduction in painful symptoms as measured by the VAS and improvement in quality of life as measured by the OHIP and OHoQL indices. There was no significant difference between the two corticosteroids in their efficacy in reducing painful symptoms (measured by the VAS) or in their effect on patient quality of life. Both FP and BSP significantly reduced the surface area of oral lesions. However, FP was statistically significantly better than BSP in reducing lesion surface area. There was no statistically significant difference between the patient-assessed effects of the 2 therapies.

CONCLUSIONS

FP and BSP are both effective in the short-term clinical management of symptomatic OLP. FP is more acceptable to patients than BSP because of the convenience of the spray form.

Gingival disorders of immune origin

Loss of the regulatory control of the immune and inflammatory defense mechanisms of the body can lead to host tissue damage, as a result of a series of complex mechanisms. In the oral cavity, and particularly in the gingival region, these dysfunctions can manifest in association to some background systemic disorder either as lesions confined to the mouth or as lesions heralding posterior florid manifestations. A review is made of the clinical changes, possible immunopathological mechanisms and diagnostic and management options in relation to pemphigus vulgaris, benign mucous membrane pemphigoid, cicatricial pemphigoid and lichen planus.

[Erosive buccal lichen planus: nine case reports]

Erosive oral lichen planus (EOLP) is uncommon. We present nine cases of EOLP in patients aged from 39 to 77 years. The aim of our retrospective study was to determine the clinical particularities and the treatment difficulties of this disease.

Serum interleukin-6 level is a useful marker in evaluating therapeutic effects of levamisole and Chinese medicinal herbs on patients with oral lichen planus

BACKGROUND

Oral lichen planus (OLP) is a T cell-mediated inflammatory disease. Interleukin-6 (IL-6) is a pro-inflammatory cytokine that has effects on cellular and humoral immunities. Previous studies have shown that keratinocytes and tissue-infiltrating mononuclear cells from OLP lesions can secrete IL-6. In some OLP patients, the high serum IL-6 levels are reduced after treatment, suggesting that IL-6 may be a useful marker in evaluating therapeutic effects and in monitoring the disease status of OLP.

METHODS

In this study, we used a solid phase, two-site sequential chemiluminescent immunometric assay to determine the baseline serum levels of IL-6 in a group of 180 patients with erosive OLP (EOLP), nonerosive OLP (NEOLP), erythema multiforme (EM), traumatic ulcers (TU), oral submucous fibrosis (OSF), pemphigus vulgaris (PV), or Sjögren's syndrome (SS), and in 77 normal control subjects. Some OLP patients were treated with levamisole plus Chinese medicinal herbs or levamisole only for 0.5-5.5 months and their serum IL-6 levels were measured after treatment.

RESULTS

We found that approximately 99% of the normal control subjects and the patients with EM, TU, or OSF had a normal serum IL-6 level less than 5.0 pg/ml. However, 15% (22/149) OLP patients, 15% (20/136) EOLP patients, 20% (5/25) major type EOLP patients, 14% (15/111) minor type EOLP patients, 15% (2/13) NEOLP patients, 14% (1/7) EM patients, 43% (3/7) PV patients, and 100% (6/6) SS patients had a serum IL-6 level greater than 5.0 pg/ml. The mean serum IL-6 level in patients with OLP (3.4 +/- 3.1 pg/ml, P < 0.001), EOLP (3.4 +/- 3.2 pg/ml, P < 0.001), major type EOLP (4.9 +/- 3.5 pg/ml, P < 0.001), minor type EOLP (3.0 +/- 3.0 pg/ml, P < 0.01), or NEOLP (4.2 +/- 1.5 pg/ml, P < 0.001) was significantly higher than that in normal control subjects (2.0 +/- 1.5 pg/ml). A significant difference in the mean serum IL-6 level was also found between major type and minor type EOLP patients (P < 0.01). The mean reduction of serum IL-6 level in OLP patients treated with levamisole plus Chinese medicinal herbs was significantly higher (7.4 +/- 4.7 pg/ml) than that in OLP patients treated with levamisole only (3.8 +/- 2.3 pg/ml, P < 0.05), suggesting that the combination therapy was superior to levamisole only.

CONCLUSION

We conclude that levamisole and levamisole plus Chinese medicinal herbs can modulate the serum IL-6 level in OLP patients. IL-6 may be a useful marker in evaluating therapeutic effects and in monitoring the disease status of OLP.

Superficial mycosis superimposing on isolated lichen planus of the lip: a case report and review of the literature

We report a case of superficial mycosis superimposing on isolated lichen planus (LP) of the lower lip that was successfully treated. A 36-year-old woman had 2 ulcerated, scaling, erythematous plaques on the lower lip for several months with mild painful sensation. Results of histologic study showed typical features of LP, but fungal hyphae were found in the horny layer. The lesion healed with only very mild residual erythema after 6 weeks of treatment. A review of the literature shows only one noted case of tinea of the lip, which was reported in 1968 by a dental practitioner, and only several cases of isolated LP of the lip. The possible mechanism of coexistence of tinea and LP of the lip is reviewed.

Treatment of severe chronic oral erosive lesions with clobetasol propionate in aqueous solution

OBJECTIVE

We sought to analyze the results of topical treatment with a mouthwash of 0.05% clobetasol in aqueous solution in 30 patients with severe oral erosive lesions.

STUDY DESIGN

Over a 48-week period, we evaluated the evolution of pain, ulcerations, atrophy, and interference of the disease in the patient's daily life, classifying the response as complete (100% remission/recovery), excellent (75%), good (50%), poor (<50%), or failed.

RESULTS

The pain and ulceration totally disappeared in 93.3% of cases and 90% reported a full recovery in their daily life activities. Atrophy response was complete in 28.5%, excellent in 60.7%, and good in 3.5%. Two patients showed no response to the treatment. Five patients suffered mild adverse effects (moon face and hirsutism) between week 4 and week 6 of treatment, which were speedily reversed by reducing the frequency of mouthwash.

CONCLUSIONS

Clobetasol mouthwash is a safe and efficacious option for the treatment of severe oral erosive lesions.

Topical tacrolimus in the treatment of symptomatic oral lichen planus: a series of 13 patients

BACKGROUND

Oral lichen planus (OLP) is a relatively common, chronic inflammatory condition, which frequently presents with symptoms of pain and irritation. OLP is often difficult to manage. Therefore there is a need for more effective and safer therapies for symptomatic OLP.

OBJECTIVE

Our purpose was to determine the effectiveness of topical tacrolimus as therapy for symptomatic OLP.

METHODS

A retrospective review was performed of 13 patients with symptomatic OLP treated with topical tacrolimus between September 1999 and September 2000.

RESULTS

Eleven of the 13 patients reported definite symptomatic response to treatment and 2 had no response. Eight patients had a partial response, whereas 3 patients had a complete response with respect to lesion clearance. Seven of the responding patients had no flares with continued treatment. The other 4 patients noted flares soon after stopping the treatment. Side effects were rare and minor.

CONCLUSIONS

In this retrospective case series of 13 patients, topical tacrolimus was well tolerated and appeared to be an effective therapy to control symptoms and clear lesions of OLP.

Management of recalcitrant ulcerative oral lichen planus with topical tacrolimus

OBJECTIVE

Our purpose was to investigate the efficacy and safety of 0.1% topical tacrolimus in erosive or ulcerative oral lichen planus.

METHODS

This was an open-label, noncomparative study conducted in an outpatient oral medicine unit in London, United Kingdom. The study covered an 8-week period with a 22-week follow-up after cessation of therapy. Nineteen patients, aged 28 to 87 years with biopsy-proven oral lichen planus refractory to, or dependent on, systemic immunosuppressive agents, were enrolled. Seventeen patients (89%) completed the study. Application of 0.1% tacrolimus was administered to all symptomatic oral mucosal lesions. Clinical review took place 1, 3, 5, 7, and 8 weeks after commencing therapy. Alleviation of symptoms was evaluated by using a visual analogue scale as well as the McGill Pain and Oral Health Impact profile questionnaires. The extent of the oral mucosal erosion or ulceration was directly measured by the same clinician at all visits. Safety assessments included monitoring of adverse events, complete blood cell count, renal and hepatic clinical chemistry, and tacrolimus blood concentrations.

RESULTS

Tacrolimus caused a statistically significant improvement in symptoms within 1 week of commencement of therapy. A mean decrease of 73.3% occurred in the area of ulceration over the 8-week study period. Local irritation (in 6 subjects, 35%) was the most commonly reported adverse effect. Laboratory values showed no significant changes with time. Therapeutic levels of tacrolimus were demonstrated in 8 subjects but were unrelated to the extent of oral mucosal involvement. Thirteen of 17 patients suffered a relapse of oral lichen planus within 2 to 15 weeks of cessation of tacrolimus therapy.

CONCLUSION

Topical tacrolimus is effective therapy for erosive or ulcerative oral lichen planus.

The treatment of oral aphthous ulceration or erosive lichen planus with topical clobetasol propionate in three preparations: a clinical and pilot study on 54 patients

BACKGROUND

This study evaluated the clinical use of a corticosteroid in three preparations (topical clobetasol propionate ointment, clobetasol propionate in an oral analgesic base, and clobetasol propionate in an adhesive denture paste).

METHODS

Fifty-four patients (34 males and 20 females) with a history of vesiculo-ulcero-erosive oral lesions were selected: 24 with oral erosive lichen planus and 30 with aphthae. The subjects enrolled were randomly divided into three groups, each of 18 patients (10 with aphthae and 8 with lichen planus): the first was treated with topical clobetasol propionate ointment (0.05%) directly on the lesion(s) three times a day; the second with clobetasol propionate in an adhesive denture paste in equal amounts (1:1) two times a day; the third with clobetasol propionate in an oral analgesic base (Orabase-B) in equal amounts (1:1) two times a day. Each subject scored his or her symptoms daily from most severe (7) to none (0) by verbal assessments using a categorical scale.

RESULTS

In all cases, the administration of the corticosteroid was effective in producing remission of symptoms in each group of patients. Significant differences (P<0.05) between groups were determined by the Kruskal-Wallis test. The Dunn test was used in order to detect which group differs from the others; clobetasol and adhesive denture paste correlated with an early remission of pain in lichen and apthous lesions.

CONCLUSION

The results suggest that topical application of clobetasol in an adhesive denture paste is an effective drug for symptomatic oral vesiculo-erosive and/or ulcerative lesions.

Levamisole and/or Chinese medicinal herbs can modulate the serum level of squamous cell carcinoma associated antigen in patients with erosive oral lichen planus

The serum levels of squamous cell carcinoma associated antigen (SCCA) were determined by a microparticle enzyme immunoassay in a group of patients with stage I oral squamous cell carcinoma (OSCC), major or minor type erosive oral lichen planus (EOLP), recurrent aphthous stomatitis (RAS), Behçet's disease (BD), oral leukoplakia (OL), or oral submucous fibrosis (OSF), and in normal control subjects. About 97% of the normal control subjects and the patients with minor type EOLP, RAS, BD, OL or OSF had a serum level of SCCA within the normal limit of 1.2 ng/ml. However, 6 of the 12 (50%) patients with stage I OSCC and 14 of the 31 (45.2%) patients with major type EOLP had a serum level of SCCA greater than 1.2 ng/ml. The mean serum level of SCCA in stage I OSCC patients (1.38+/-1.16 ng/ml) or in major type EOLP patients (1.32+/-1.23 ng/ml) was significantly higher than that in normal control subjects (P<0.001) and that in the patients with minor type EOLP (P<0.001), RAS (P<0.001), BD (P<0.05), OL (P<0.05), or OSF (P<0.05). Either major or minor type EOLP patients could obtain a significant mean reduction of the serum SCCA level of 0.34-0.63 ng/ml after treatment with levamisole and/or Chinese medicinal herbs for 1-30 months. Combination therapy with levamisole plus Chinese medicinal herbs could achieve a shorter duration of treatment to get complete remission than the single therapy with either levamisole only or Chinese medicinal herbs only. We conclude that levamisole and/or Chinese medicinal herbs can modulate the serum SCCA level in EOLP patients. SCCA may be a useful marker in evaluating therapeutic effects and in monitoring the disease status of EOLP. For EOLP patients, the combination therapy is superior to the single therapy of levamisole or of Chinese medicinal herbs.

Oral lichen planus: patient profile, disease progression and treatment responses

BACKGROUND

Oral lichen planus, or OLP, is a common mucocutaneous immunological disease. The objective of this study was to describe the patient profile, disease progression and treatment responses.

METHODS

The authors conducted a retrospective, descriptive study using information from patient records at a tertiary referral center. The study included 229 patients with OLP who were seen in the oral medicine clinic at the University of California, San Francisco, between September 1996 and August 2000, for the first time or for a follow-up visit. Signs and symptoms at various clinic visits were quantified. Responses to treatment and disease progression were determined by comparing scores with baseline scores.

RESULTS

The mean age at onset of the disease was 55 years, and 154 (67 percent) of the patients were female. Symptoms generally correlated directly with the severity of OLP forms, which ranged from reticular to erosive. Corticosteroids were effective in reducing symptoms, healing ulcers and reducing erythema. At last follow-up, 65 percent of the patients had the same type of OLP seen initially or the disease had progressed to a more severe type, while 35 percent of patients had less-severe forms than that seen at the initial visit. Four patients (1.7 percent) developed oral squamous-cell carcinoma during the follow-up period.

CONCLUSIONS

OLP is a chronic disease with no known cure. Symptoms can improve with corticosteroids; however, the lack of long-term (that is, lifetime) treatment compliance and the adverse side effects of the drugs limit optimal results.

CLINICAL IMPLICATIONS

Patients with OLP should be treated if symptoms are significant. Follow-up--including supervision of medication use and monitoring of side effects, as well as periodic examinations for possible malignant transformation--is necessary.

The bullous desquamative lesions of oral mucosa

The most common of the bullous/desquamative diseases that affect the mouth include the erosive form of lichen planus, erythema multiforme, pemphigoid, and pemphigus. This overview looks at the clinical features and diagnosis of these diseases. In addition, treatment options are discussed.

Cushing's syndrome from Klack's solution

OBJECTIVE

To report, for the first time, a case of Cushing's syndrome from the use of Klack's solution, a multipurpose remedy composed of various pharmaceutical agents with a glucocorticoid as one of the active ingredients.

METHODS

A case report of Cushing's syndrome is presented, and the different components of Klack's solution are compared.

RESULTS

In a 36-year-old man with the development of Cushing's syndrome, the use of Klack's solution for the treatment of oral lichen planus was incriminated. For the evaluation of Cushing's syndrome, all potential sources and doses of corticosteroids, as well as the patient's compliance with dosing instructions, must be examined. In this case, the Klack's solution, which can be prepared in multiple versions and strengths at the discretion of the prescriber, had a high content of corticosteroid.

CONCLUSION

Health-care providers should be reminded of the potency and potential harm of corticosteroids by this unusual case of Cushing's syndrome attributable to Klack's solution.

Oral lichen planus: a review

Oral lichen planus is a disease that can persist in some patients for a long time. The buccal mucosa, tongue and gingiva are the most common sites, whereas palatal lesions are uncommon. Oral lichen planus affects women more often than men in a ratio of 2:3. It can present in a number of forms: reticular, papular, plaque-like, erosive, atrophic and bullous. The question of malignant transformation of oral lichen planus remains controversial. The management can be non-surgical or surgical and the choice of treatment may vary from patient to patient and depends on the choice of the clinician.

The management of oral lichen planus

Oral lichen planus is a relatively common inflammatory disease affecting between 0.5% and 2.2% of the population in epidemiological studies. In contrast with cutaneous lichen planus (LP), in which the clinical course is often mild and resolves within 2 years, mucosal LP tends to follow a more chronic course often punctuated by acute exacerbations. Furthermore, although distinct clinical subtypes such as reticular, atrophic, hypertrophic and erosive forms are well recognized, more than one clinical phenotype may be seen at a time. The rare association with oral neoplasia should always be considered and high-risk patients must be kept under close observation. Thus the management of this disorder will vary widely both between patients, and for individual patients, with fluctuations in disease activity. Here we discuss the therapeutic options available and review the evidence for their use.

[Research of compound cyclosporin A mouthwash in the treatment of oral lichen planus]

Thirty patients of oral lichen planus(OLP) were treated with compound CyA mouthwash, while the control group was treated with KouTai. The results showed that the rate of success and total rate of success of patients treated with compound CyA mouthwash were 63 percent and 97 percent respectively, but those of the control group treated with kouTai were 10 percent and 63 percent respectively. There was a statistically significant difference(P < 0.01). No side-effects were found. The mouthwash is an effective, safe and local drug used in the treatment of OLP.

[Study on regulatory effect of composite taixian tablet on immune function of red blood cell in patients with oral lichen planus]

OBJECTIVE

To explore the regulatory effect of Composite Taixian tablet (CTXT) on red blood cell (RBC) immune function in patients with oral lichen planus (OLP) for the sake of providing the basis of clinical medication.

METHODS

Sixty patients with OLP were assigned randomly into three groups and were treated by CTXT, Tripterygium hypoglaucum tablet and polyactin-A tablet respectively. And the changes of RBC-C3b receptor and immune circulating rosette complex on the surface of erythrocytes (RBC-ICR) were measured by saccharomycetic assay.

RESULTS

Effect of CTXT was superior to that of Tripterygium hypoglaucum and polyactin-A tablets.

CONCLUSION

CTXT is a relatively effective remedy with less side effect, it is worthy to be studied further.

New and emerging therapies for diseases of the oral cavity

It is obvious from the review of the literature that most treatments for oral diseases such as lichen planus, pemphigoid, and pemphigus are based on case reports, anecdotes, and small uncontrolled studies. Efforts must be made to perform more controlled studies to evaluate the efficacy of new treatments. Small numbers of patients at each site and multiple-drug therapy make this task difficult. Dermatologists should familiarize themselves with the newer immunosuppressive agents available. Use of these drugs requires knowledge of their pharmacokinetics and potential side effects, so that they may be used effectively and safely. Relatively low doses of azathioprine, cyclophosphamide, and cyclosporine should then be added to the dermatologist's armamentarium for the treatment of severe or recalcitrant diseases. Old drugs are resurfacing with new (but often off-label) uses as the underlying mechanisms of disease become understood. Thalidomide and mycophenolate mofetil are two examples of promising drugs for the future of dermatology.

Efficacy of fluocinolone acetonide gel in the treatment of oral lichen planus

OBJECTIVE

The purpose of this study was to compare the efficacy of fluocinolone acetonide gel 0.1% in 2 base forms (numbers 1 and 2) with fluocinolone acetonide in an oral base 0.1%.

STUDY DESIGN

Forty-eight patients with histologically confirmed oral lichen planus were enrolled in the study. Lesions were scored ranging from 0 (no lesion) to 5 (large erosion) according to the severity. Patients were randomly given fluocinolone acetonide in an oral base, fluocinolone acetonide gel no. 1 or no. 2. They were asked to apply the medication on dried lesions 4 times a day. The lesions were evaluated after 2 and 4 weeks of treatment. The severity scores were analyzed by the Kruskal-Wallis k-sample test.

RESULTS

Patients who received fluocinolone acetonide in an oral base and those who received fluocinolone acetonide gel no. 1 and no. 2 improved from the average score of 3.0, 3.0, and 2.9 to 1.5, 1.5, and 1.6, respectively. There were no statistically significant differences in score changes noted in the 3 groups. The results indicate that fluocinolone acetonide gel no. 1 and no. 2 and fluocinolone acetonide in an oral base provide similar efficacy in the treatment of oral lichen planus.

CONCLUSION

Fluocinolone acetonide gel 0.1% is a safe and effective alternative therapy to fluocinolone acetonide in an oral base 0.1% in the treatment of oral lichen planus.