Clinical management of oral lichen planus

Oral lichen planus is a relatively common chronic disease of the mucous membranes which may have more transient cutaneous manifestations. It has a number of well-recognized clinical signs and a wide range of symptoms from none through mild discomfort to severe debilitating intra-oral erosions and ulceration. It often does not respond to treatment and, in a small proportion of cases, undergoes malignant transformation to squamous cell carcinoma. Although there is an array of treatments, they are palliative rather than curative. Corticosteroids in various forms remain the mainstay of treatment but newer immunomodulatory agents have an increasing role. In this paper, we review current thinking about the management of oral lichen planus and summarize a recent European consensus protocol.

Patient with lichen planus and conjunctival immunopathologic features of lupus erythematosus

PURPOSE

To report a case of severe cicatricial conjunctivitis in a patient with lichen planus, which is known to affect the skin and mucous membranes. The conjunctival immunopathologic features were consistent with lupus erythematosus rather than with lichen planus.

METHOD

Oral mucosal and skin biopsies were performed with histopathologic and immunofluorescent studies consistent with lichen planus. The patient later had a biopsy of cicatrized conjunctiva with histopathologic and immunofluorescent findings consistent with lupus erythematosus. Evaluation by rheumatology and dermatology consultants demonstrated no evidence of active systemic lupus erythematosus or discoid lupus erythematosus.

RESULTS

The patient was treated with topical and systemic immunosuppressives and her disease eventually stabilized.

CONCLUSION

The case demonstrates two coexisting autoimmune disease entities: lichen planus of the skin and oral mucosa and a cicatricial conjunctivitis consistent with lupus erythematosus.

The management of oral lichen planus

OBJECTIVE

To review the current literature regarding the medical treatment of oral lichen planus (OLP).

DATA SOURCES

PubMed on-line Medline data searches were carried out for the years 1966-1998 to identify reports on therapy of OLP.

METHODS OF STUDY SELECTION

Single case reports or open trials were included if they covered new therapeutic approaches or suggested significant modifications of known treatment modalities. Review papers were limited to those dealing with the topic.

DATA EXTRACTION AND SYNTHESIS

Every paper was critically examined. Because of the great heterogeneity of the response criteria, many data could not be directly compared. Stronger weight was given to therapies that have proven to be effective under placebo-controlled research protocols. Attention was also drawn to potential and effective adverse effects of every drug used.

CONCLUSIONS

Among the various medications advocated for the treatment of OLP, several lack conclusive findings from adequately controlled trials. Mainly high-potency topical corticosteroids in an adhesive medium appear at present the safest and most efficacious. Adjuvant agents as antimycotics may be useful in topical steroid treatment. Systemic corticosteroids may be occasionally indicated for severe recalcitrant erosive OLP or for diffuse mucocutaneous involvement. Topical cyclosporine should be considered in steroid-unresponsive cases considering that its efficacy in OLP could be related to a systemic effect and its high cost. Classical PUVA therapy seems to have too many side effects; topical application of psoralen is promising but still experimental. Topically and systemically delivered retinoids combined with topical corticosteroids could improve the efficacy of these agents whereas complete remission is difficult to achieve with retinoids alone and they frequently cause adverse effects. Finally, there are only few data concerning the long-term effect of the medical treatments upon the course of OLP and we do not know if therapy influences the malignant evolution of OLP.

Strategies for management of commonly encountered oral mucosal disorders

Oral mucosal disorders are frequently encountered by the practicing dentist. These lesions may represent oral manifestations of dermatologic or systemic disease, reactive lesions, or occult neoplasms. The diagnosis of these conditions is usually based on case-specific historical findings, clinical appearance, and the results of diagnostic procedures. This article will discuss the diagnosis and management of commonly occurring oral mucosal conditions such as candidosis, recurrent aphthous ulceration, herpes virus infection, and lichen planus. This manuscript represents a synthesis of the literature and the management approach utilized by the author in the treatment of his patients. This article is not intended as a comprehensive review of all the subjects discussed.

Topical corticosteroids in association with miconazole and chlorhexidine in the long-term management of atrophic-erosive oral lichen planus: a placebo-controlled and comparative study between clobetasol and fluocinonide

OBJECTIVE

To evaluate the efficacy of a combination of topical corticosteroids with topical antimycotic drugs in the therapy of atrophic-erosive forms of oral lichen planus (OLP).

PATIENTS AND METHODS

The study population consisted of 60 patients with OLP subdivided into three groups matched for sex and age. The first group (25 patients) and the second group (24 patients) received respectively 0.05% clobetasol propionate ointment or 0.05% fluocinonide ointment in an adhesive medium (4% hydroxyethyl cellulose gel) plus in each case antimycotic treatment consisting of miconazole gel and 0.12% chlorhexidine mouthwashes. The third group (11 patients), placebo group, received only hydroxyethyl cellulose gel and antimycotic treatment as above. All the treatment regimens were carried out for 6 months. Each patient was examined every 2 months during the 6-month period of active treatment and for a further 6 months of follow-up. Objective and subjective clinical progress was scored and compared between the three groups. Plasma cortisol levels were monitored in half the patients using the topical corticosteroids.

RESULTS

All patients treated with clobetasol and 90% of the patients treated with fluocinonide witnessed some improvement, whereas in the placebo group only 20% of patients improved (P < 0.0001 and P = 0.00029, respectively. However, when considering complete responses, only clobetasol gave significantly better results than placebo. Clobetasol resolved 75% of the lesions whereas fluocinonide was effective in 25% of cases and placebo in none. Clobetasol achieved better results statistically than did fluocinonide (P = 0.00442) and placebo (P = 0.00049) whereas there was no statistical difference among fluocinonide and placebo (P = 0.140). Similar results were obtained for symptoms. Both drugs were shown to be effective in the treatment of erosive lesions, but clobetasol was considerably more efficacious than fluocinonide in the atrophic areas (75% vs 25% of total response, respectively) (P = 0.00442). None of the treated patients contracted oropharyngeal candidiasis. After 6 months of follow-up, 65% of the clobetasol-treated group and 55% of the fluocinonide group were stable. Estimation of plasma cortisol levels showed no significant systemic adverse effects of clobetasol or fluocinonide.

CONCLUSIONS

Our results suggest that a very potent topical corticosteroid such as clobetasol may control OLP in most cases, with no significant adrenal suppression or adverse effects. Moreover, a concomitant antimycotic treatment with miconazole gel and chlorhexidine mouthwashes is a useful and safe prophylaxis against oropharyngeal candidiasis.

Efficacy of topical mesalazine compared with clobetasol propionate in treatment of symptomatic oral lichen planus

OBJECTIVE

To compare topically applied mesalazine (5-aminosalicylic acid) to topically applied clobetasol propionate in the treatment of patients suffering from symptomatic oral lichen planus.

DESIGN

Randomized controlled longitudinal investigation.

PATIENTS AND METHODS

Twenty-five out-patients suffering from oral lichen planus and referred to the Department of Oral Pathology and Oral Medicine of the University of Milan, Italy, during the period January to August 1997. Patients were randomly allocated (Group A and Group B) to treatment with mesalazine 5% or clobetasol propionate 0.05%. The drugs were topically applied twice daily for 4 weeks. Discomfort and pain were evaluated by the patient before and after treatment using a Visual Analogue Scale from zero (no pain) to 10 (extreme pain). Results were statistically evaluated by a Mann-Whitney U test.

RESULTS

The two pharmacological regimens obtained partial and complete absence of symptoms. In particular, the mesalazine tested group disclosed 57% complete absence of symptoms, 21.3% partial response and 9% no response. No statistically relevant difference has been detected between the two regimens.

CONCLUSIONS

The results of this preliminary study, if confirmed by further investigations, suggest that mesalazine might be considered an alternative to clobetasol propionate for treatment of symptomatic oral lichen planus.

Response to levamisole and low-dose prednisolone in 41 patients with chronic oral ulcers: a 3-year open clinical trial and follow-up study

OBJECTIVE

The purpose of this open clinical trial and follow-up study was to evaluate the short-term and long-term clinical efficacy of levamisole used with low-dose prednisolone in 30 patients with oral lichen planus, 6 patients with erythema multiforme, 3 patients with mucous membrane pemphigoid, and 2 patients with early pemphigus vulgaris.

STUDY DESIGN

All patients were given 150 mg/day of levamisole and 15 mg/day of prednisolone for 3 consecutive days each week, along with topically applied dexamethasone orobase (dexaltin).

RESULTS

Twenty-three patients showed dramatic remission of signs and symptoms within 2 weeks; 18 patients experienced partial remission. Forty patients reported significant pain relief, and almost none showed evidence of oral ulcerative lesions after 4 to 8 weeks of treatment. In contrast, 1 patient with oral lichen planus with allergy to levamisole reported a partial response from prednisolone alone. All 29 patients with oral lichen planus remained free from symptoms for more than 6 months. All 6 patients with erythema multiforme, all 3 patients with mucous membrane pemphigoid, and both patients with pemphigus vulgaris also remained free from symptoms for 2 to 3 years. There were few side effects from the treatment; there was minor skin rash from levamisole in 1 case of oral lichen planus. We also designed a flexible plastic carrier for topically applied dexaltin in the treatment of diffuse atrophic or ulcerative gingivitis.

CONCLUSIONS

The addition of levamisole to prednisolone may produce improved results in the management of erosive lichen planus, erythema multiforme, mucous membrane pemphigoid, and early pemphigus vulgaris.

Systemic corticosteroid therapy of oral vesiculoerosive diseases (OVED). An open trial

BACKGROUND

We report the preliminary findings from our open study on how to optimize the doses and the response times to systemic corticosteroid therapy for three forms of oral vesiculoerosive diseases (OVED).

METHODS

All twenty-one patients enrolled in the study were affected with OVED (10 OLP, 6 MMP, 5 EM) and received different doses of prednisone in relation to the type of disease and its severity. Daily mouthwashes with 0.12% chlorhexidine and application of miconazole gel were added to the therapy; its response time to treatment varied individually, the doses were reduced only after 75% of lesions had cleared.

RESULTS

The average response time to treatment was 28 days. Clinical assessment showed that 95% of the patients had improved, whereas 71% had complete remission of oral signs and 48% experienced side effects. The degree of clinical resolution was: 70% complete remission after 26 days of therapy in patients with OLP, 33% complete remission after 38 days in patients with MMP, and 100% complete remission after ten days in patients with EM.

CONCLUSIONS

Although a preliminary study, initial results showed different types and times of response to systemic corticosteroid treatment for the three diseases. Our findings strongly suggest that a unified therapeutic protocol for different OVED is not advisable, nor can systemic treatment be considered the first therapeutic approach.

Aqueous hydrocortisone mouthwash solution: clinical evaluation

Patients often experience difficulties in applying topical steroids in orabase to the oral mucosa, particularly when large areas need to be covered. An aqueous hydrocortisone mouthwash solution has been developed, one that was anticipated to be more acceptable to patients. The solution contains hydrocortisone (0.3% w/v) in a 4.5% (w/v) 2-hydroxypropyl-beta-cyclodextrin solution. Hydroxypropylmethylcellulose (0.5% w/v) was used to increase the viscosity of the solution and to promote the hydrocortisonecyclodextrin complex. One hundred and two patients with aphthous ulceration, lichen planus, and other mucosal conditions used the mouthwash in an open clinical efficacy study. Most patients reported some or considerable improvement following a 2-week course of treatment with the mouthwash: 26 of 33 (78.8%) patients with aphthous ulceration were 'much better', as were 26 of 54 (48.1%) patients with lichen planus and 5 of 16 (31.3%) patients with other mucosal lesions. No serious side effects were reported. Aqueous mouthwash solutions offer a potential vehicle for topical steroid therapy of oral mucosal lesions.

Low-dose low-molecular-weight heparin (enoxaparin) is beneficial in lichen planus: a preliminary report

BACKGROUND

Low-dose heparin devoid of anticoagulant activity inhibits T-lymphocyte heparanase activity, which is crucial in T-cell migration to target tissues.

OBJECTIVE

The purpose of this study was to assess the efficacy of low-dose enoxaparin (Clexane), a low-molecular-weight heparin, as monotherapy in lichen planus.

METHODS

Included in the study were 10 patients with widespread histopathologically proven lichen planus (LP) associated with intense pruritus of several months' duration. Patients were given 3 mg enoxaparin, subcutaneously once weekly; three patients received four injections, and seven patients received six injections.

RESULTS

In nine patients the itch disappeared within 2 weeks. Within 4 to 10 weeks in eight of these patients, there was complete regression of the eruption with residual postinflammatory hyperpigmentation; in one patient, there was marked improvement. In one patient, no effect was observed. Of the four patients who also had oral LP, only one showed improvement. No side effects were observed in any of the patients.

CONCLUSION

These findings indicate that enoxaparin may be a simple, effective treatment for cutaneous LP.

Update on oral lichen planus: etiopathogenesis and management

Lichen planus (LP) is a relatively common disorder of the stratified squamous epithelia, which is, in many ways, an enigma. This paper is the consensus outcome of a workshop held in Switzerland in 1995, involving a selection of clinicians and scientists with an interest in the condition and its management. The oral (OLP) eruptions usually have a distinct clinical morphology and characteristic distribution, but OLP may also present a confusing array of patterns and forms, and other disorders may clinically simulate OLP. Lesions may affect other mucosae and/or skin. Lichen planus is probably of multifactorial origin, sometimes induced by drugs or dental materials, often idiopathic, and with an immunopathogenesis involving T-cells in particular. The etiopathogenesis appears to be complex, with interactions between and among genetic, environmental, and lifestyle factors, but much has now been clarified about the mechanisms involved, and interesting new associations, such as with liver disease, have emerged. The management of lichen planus is still not totally satisfactory, and there is as yet no definitive treatment, but there have been advances in the control of the condition. There is no curative treatment available; immunomodulation, however, can control the condition. Based on the observed increased risk of malignant development, OLP patients should be offered regular follow-up examination from two to four times annually and asked to report any changes in their lesions and/or symptoms. Follow-up may be particularly important in patients with atrophic/ulcerative/erosive affections of the tongue, the gingiva, or the buccal mucosa. Much more research is required into the genetic and environmental aspects of lichen planus, into the premalignant potential, and into the possible associations with chronic liver, and other disorders. More clinical studies are required into the possible efficacy of immunomodulatory drugs such as pentoxifylline and thalidomide.

Isolated lichen planus of the lip successfully treated with chloroquine phosphate

Solitary lesions of lichen planus (LP) are often confused with other inflammatory or malignant epithelial lesions. We describe a 51-year-old woman who had had an LP of the lower lip for 11 years. She had undergone several oral and topical therapies with little improvement. The patient had an excellent response to chloroquine phosphate within 3 months. This report represents the third case of LP exclusively localized on the lower lip.

[Immunoregulation effect of traditional Chinese medicine treatment on patients with oral lichen planus]

OBJECTIVE

To explore effect of traditional Chinese medicine (TCM) treatment on immune state of patients with oral lichen planus (OLP).

METHODS

30 cases of patients with OLP were treated by TCM and peripheral blood T-lymphocyte subgroup in these patients were determined.

RESULTS

CD3, CD4 and CD4/CD3 ratio of patients with OLP were decreased significantly, compared with that of health people (P < 0.01) before TCM treatment, while after TCM treatment CD3, CD4 and CD4/CD3 ratio were increased significantly (P < 0.01) and the latter recovered to normal, 8 patients recovered, 14 cases significantly improved, and 8 cases improved.

CONCLUSION

TCM therapy is useful for the treatment of OLP. It acts biphasically a regulation effect on the immunologic balance of the patient.

Oral lichen planus: topical and systemic therapy

The treatment of oral lichen planus (OLP) remains a real challenge for clinicians who deal with this patient population and thus with diagnosis of this disease. Most treatment failures are attributable to improper diagnosis. Therefore, before a patient is started on therapy, a biopsy must be done and the diagnosis established. Most patients with OLP are asymptomatic, and once the diagnosis is established, patients need to be seen once a year to monitor their disease. However, when OLP is symptomatic, it can interfere with the patient's everyday life, making it difficult to work and to eat. The most symptomatic forms of the disease are the erosive and atrophic types. Often, systemic therapy is the only way to control the acute presentation of the disease. The most effective treatment modality to control the signs and symptoms of the disease is short courses of systemic steroids (prednisone) and topical high-potency corticosteroids. Other forms of therapy include the use of cyclosporine (topical) and retinoids, both systemic (etretinate) and topical (tretinoin). However, there is no one single standard protocol proven effective with either systemic retinoids or topical cyclosporine. Results so far are controversial and not very encouraging. One aspect clinicians must remember when designing treatment protocols for erosive OLP is the chronic course of the disease and its recalcitrant nature. These factors mean that treatment has to be long, and the onset of adverse side effects from long-term therapy must be taken into account. Alternate-day treatment protocols, low doses, and adjunct therapy all should be considered when a new agent is being considered for treating erosive OLP.

Oral lichen planus update: clinical characteristics, treatment responses, and malignant transformation

PURPOSE

To assess the current profile and the natural disease history of patients with oral lichen planus (OLP) and evaluate their responses to treatment.

MATERIALS AND METHODS

Ninety-five community-referred patients with OLP, who were examined in our Oral Medicine Clinic between May 1995 and August 1996, comprised the study group.

RESULTS

The OLP patients had been followed for 1-20 years (mean 6.1). The average age at first-recognized onset was 59 years, and there was a 2.3 to 1 female predominance. Only five of the patients knew of a family history of lichen planus. There were no evident associations with smoking, candida, systemic disease or medications. Of the 222 involved mucosal sites, the buccal mucosa was involved most often (79%) and the erosive form was most frequent. Of 70 patients who received systemic and/or topical corticosteroid treatment for pain (83%) or annoying irritation (17%), all but five obtained complete or satisfactory relief. A squamous cell carcinoma developed at a lesion site in three patients (3.2%) during the observation period.

An open clinical trial of a new mouth-PUVA variant in the treatment of oral lichenoid lesions

OBJECTIVE

To investigate the feasibility of topical psoralen PUVA (sensitization in photosensitizing psoralen drug + UVA radiation) treatment of oral lichenoid lesions (OLL).

STUDY DESIGN

A total of 16 patients with OLL were treated using a 0.01% trioxsalen ointment and UVA doses in the 0.09 to 1.80 J/cm2 range. The average number of sessions was 8.7 and a mean cumulative irradiation dose was 4.25 J/cm2.

RESULTS

A marked-to-complete healing occurred in 3 to 16 (19%) patients immediately after therapy, in 4 of 14 (29%) after 3 months, and in 5 of 14 (38%) after 14 months, respectively. Of the 16 subjects with OLL, five were diagnosed as oral lichen planus (OLP) and 11 were classified as oral lichenoid reaction (OLR). Post-PUVA amelioration rate in patients with genuine OLP (4 of 5, 80%) was superior to that in patients with OLR (1 of 9, 11%).

CONCLUSION

Topical trioxsalen photosensitization can be used in mouth-PUVA treatment, and lichen planus is a main indication for this therapy.

Oral lichen planus: parameters affecting accurate diagnosis and effective management

Oral lichen planus is one of the most common mucosal diseases that require management by the dental practitioner. The gingival presentation of this disease can be particularly problematic. Accurate diagnosis is of paramount importance for effective management, and tissue specimens are often required to distinguish this disease from other vesiculo-ulcerative diseases. The lichen planus patient can generally be managed with topical steroids. The use of antibiotics may be an important adjunctive consideration for patients with a concurrent significant periodontal condition. The possibility of carcinoma arising in lichen planus lesions is addressed. The learning objective of this article is to define specific parameters that contribute to the definitive diagnosis in order to promote objective, rather than empirical, treatment and to delineate specific points to address in patient education.

[Topical treatment of atrophic-erosive oral lichen planus with clobetasol in bioadhesive gel as well as chlorhexidine and miconazole in oral gel]

The study was performed to evaluate the efficacy of the combination of a topical corticosteroid with topical antimicrobic drugs in the therapy of the atrophic-erosive forms of oral lichen planus. Clobetasol propionate, a very potent corticosteroid in the Miller and Munro classification, was used in a 4% hydroxy ethylcellulose bioadhesive gel and applied twice daily for the first four months and once daily for the last two months. Because of the high frequency of candidal infections during corticosteroid therapy, chlorhexidine 0.12%, 3 mouthwashes daily, and miconazole gel, once daily, were added for the whole period of the treatment. Twenty-five patients (17 female, 8 male) participated in the study; 20 concluded the six months of therapy and the six months of follow-up. All 20 patients (100%) had an improvement, while 75% had a complete remission of oral signs. No cases of oral candidiasis were seen. After six months from therapy suspension, 65% of patients were stable in their oral conditions. Our study confirms the efficacy of the combination of a topical corticosteroid with topical antimicrobic drugs in the therapy of the atrophic-erosive forms of oral lichen planus. The stability of our results suggests that, extending the therapy, control of the disease is better.

[A study of therapeutic efficacy of Koukangning gargle in the treatment of oral mucositis]

A study of therapeutic efficacy was carried out in 118 patients with oral mucositis (recurrent oral aphthous ulceration, erosive lichen planus, herptic stomatitis and infectious oral mucosal hematoma) at random. As a topical medication, Koukangning gargle was applied to 59 patients of the experimental group, 29 patients of the control group 1 applied Dobell's solution to rinse their mouths, and 30 patients of the control group 2 applied Koutai solution. A satisfactory result was observed in the experimental group, its effectiveness and effective rates rose more than those of control group 1 at both treatments for 3 days and 6 days. Between the two groups, there were markedly significant difference (P < 0.005, P < 0.01, P < 0.005, P < 0.005). Koukangning gargle was nontoxic and no side-effects in the clinical tests. Its efficacy was no significant difference compared with the control group 2. Experimental study demonstrates that it possesses anti-inflamation effect and excellent antibiotic effect, therefore it is a new gargle for rinse mouth combined traditional Chinese medicine with Western medicine.

Efficacy of topical retinoic acid compared with topical fluocinolone acetonide in the treatment of oral lichen planus

The purpose of this study was to compare the efficacy of retinoic acid in an oral base 0.05% with fluocinolone acetonide in an oral base 0.1% in the treatment of atrophic and erosive oral lichen planus. Thirty-three patients with histologically proven oral lichen planus were asked to participate in the study. Lesions were scored ranging from 0 (no lesion) to 5 (large erosion) according to the severity. Patients were randomly assigned to receive either topical fluocinolone acetonide or topical retinoic acid. They were instructed to apply the medication on dried lesions four times a day. The lesions were evaluated after 2 and 4 weeks of treatment. The sign scores were analyzed by the Wilcoxon rank sum test. Eighteen patients receiving topical fluocinolone acetonide improved from the average score of 3.0 to 1.5 after 4 weeks of treatment, whereas 15 patients receiving topical retinoic acid showed little change (average score, 2.9 and 2.4, respectively). The changes were statistically significantly different between the two groups (p = 0.01). The results suggest that 0.1% fluocinolone acetonide reduced the severity of atrophic and erosive oral lichen planus better than 0.05% retinoic acid.

Clinical characteristics and treatment of patients with oral lichen planus in Israel

Oral lichen planus (OLP) has a multiple-site involvement, with the buccal mucosa being the most prevalent. A possible relationship between OLP and the risk of malignancies in the involved site is documented. The characteristics of OLP have been studied in different populations; however, no similar studies have been conducted in any Jewish population. The purpose of this study was to evaluate the natural history of OLP in Israeli Jewish patients. Data were collected from 157 charts of patients with histologically confirmed OLP. No evidence suggesting a connection between OLP and diabetes, cardiovascular disease, smoking, alcohol use, or positive Candida culture was found. Skin involvement of lichen planus was found in one fifth of the patients. Symptomatic OLP was noted in half of the patients, mainly in those with the erosive form. In 65% of the patients with symptoms, improvement by more than 50% was shown within 2 weeks of steroid use. The transformation rate of 1.3% of OLP into malignancy was observed in the entire group. A constant follow-up for contributing symptoms and for early diagnosis of suspected transformed lesions is of utmost importance.

Topical cyclosporine in a bioadhesive for treatment of oral lichenoid mucosal reactions: an open label clinical trial

Oral lichenoid reactions may present as chronic symptomatic mucosal reactions. Lichen planus-like reactions include those associated with drug reactions, graft-versus-host disease after bone marrow transplantation, and idiopathic lichen planus. The mainstay of management is topical steroids; in resistant cases, topical and systemic corticosteroids may be used. We evaluated the use of cyclosporine administered in an adhesive hydroxypropyl cellulose base in patients with oral lichenoid reactions that remained active despite the prior use of high-potency topical steroids and in some cases despite the combined use of topical and systemic immunosuppression. Signs and symptoms of ulcerative oral graft-versus-host-disease improved more than 50% in three of four patients with oral graft-versus-host disease treated with the addition of topical cyclosporine. However, in patients with persistent oral lichen planus less effect was seen with 7 of 14 patients demonstrating a partial reduction in signs and symptoms. The topical use of cyclosporine in a bioadhesive base may represent a useful adjunctive approach in management of oral lichenoid reactions, although dose escalation and placebo-controlled studies are needed.

[Oral lichen planus (OLP). Therapeutic guidelines and clinical experience with 71 patients]

The authors report the results of a study performed in 71 patients suffering from lichen planus of the mucous membranes and skin. They discuss dermatological and stomatological clinical data in relation to possible basal diseases (hepatopathies, dermopathies, diabetes, hypertension, gastrointestinal diseases, etc.) and other anamnestic data (psychological aspects, drug taking, working activity, etc.). Moreover, they report the results of the clinical protocol used (betamethasone in a gel and vitamin A base) with a follow-up of 5 years and examine the other therapeutic possibilities reported in the literature.

Effectiveness of glycyrrhizin for oral lichen planus in patients with chronic HCV infection

Oral lichen planus (OLP), an intractable inflammatory disease characterized by a band-like lymphocytic invasion under the oral mucosa, is frequently associated with hepatitis C virus (HCV) infection. We investigated the effects of glycyrrhizin, which is used to treat chronic liver dysfunction, in nine patients with OLP who were positive for HCV antibody and HCV RNA. A control group, eight patients with OLP who were also positive for HCV antibody and HCV RNA, was given only dental cleaning. Glycyrrhizin (GL) was given intravenously, at a dose of 40 ml (0.2% solution) daily, for 4 consecutive weeks. Six (66.7%) of the nine patients given GL improved clinically (P = 0.0141 vs non-GL group), suggesting that GL is useful in treating OLP.

Topical steroid therapy in oral lichen planus: review of a novel delivery method in 24 patients

Lichen planus is a chronic mucocutaneous disorder of unknown etiology. The natural progression of oral lichen planus (OLP) is long and can extend over a number of years. Although many patients with OLP remain asymptomatic, some experience periods of marked inflammation with breakdown of the lesions, and require treatment. Corticosteroids are the mainstay of treatment for oral lesions, but delivery to affected mucosal sites can be problematic. The purpose of this study was to retrospectively review the results of topical steroid therapy in a group of patients with OLP, using a novel delivery method. The records of 33 patients with biopsy-proven OLP were reviewed and the relevant clinical features were noted at minimum review intervals of one, six and 12 months. Of this group, 24 patients had been treated using a standardized treatment protocol consisting of a corticosteroid ointment applied topically to mucosal lesions using cloth strips. Gingival lesions were treated using a steroid preparation in an adhesive paste. Nine patients remained asymptomatic and were not treated. In the treated group, 14/24 (58 per cent) of patients showed an improvement in symptoms by one month. The remainder showed no change or a worsening of their symptoms. Repetition of the treatment protocol resulted in improvement in all the non-responders, and by one year 23 of 24 (96 per cent) of the patients had experienced improvement or control of their symptoms. Long-term failure to control the symptoms in the single non-responding case was related to poor patient compliance. Results from this study show that a novel delivery method and treatment protocol for the application of topical steroids onto lesional mucosa is useful for the symptomatic control of oral lichen planus.

Diagnosis and management of oral lichen planus

OLP has many clinical presentations. Some lesions of OLP require no treatment. Some must be managed for 20 years or more. The differential diagnosis of OLP is difficult and varied. Dermatologists should consider consultation with a dentist or specialist in oral medicine for diagnosis and management of lesions of OLP.

[The topical treatment of atrophic-erosive oral lichen planus with fluocinonide in a bioadhesive gel, chlorhexidine and miconazole gel. A totally open trial]

To evaluate the efficacy and long-term course of topical steroids treatment in oral lichen planus (OLP), an open trial has been carried out in 30 patients with atrophic-erosive or symptomatic varieties of OLP confirmed histologically with relative contraindications for systemic steroid treatment (namely, liver disease, peptic ulcer, diabetes, blood hypertension or osteoporosis). The treatment was the following: Fluocinonide (Topsyn) 0.025% in 4% idrossiethylcellulose gel applied 3 times/daily for two months, 2 times/daily for the next 2 months and 1 times/daily for other 2 months. Moreover, chlorhexidine (Plakout) 0.12%, 3 mouthwashes/daily and miconazole gel (Micotef) applied 1 times/daily were used for the entire period of the steroid therapy as antimycotics. The clinical evaluation of signs and symptoms was assessed on a scale of 0 to 5 and of 0 to 3, respectively. Twenty patients concluded the entire therapeutical scheme, whereas 5 (17%) interrupted the treatment for the appearance of side-effects (namely, gastroesophageal disturbances, mucosal bleeding and pruritus), 1 interrupted voluntarily the treatment and 4 cases did not present at the controls. No cases of oral candidiasis were seen. Eighteen patients (90%) had improvements of oral lesions with significant statically reductions in the scores of signs (p < 0.002) and of symptoms (p < 0.02) (Wilcoxon test). We emphasize also that in 61% of the responders the oral conditions were stable after 6 months of follow-up. In conclusion our results suggest the following: a) fluocinonide is an effective and safe drug for the treatment of OLP, especially in addition with chlorehixidine and miconazole; b) the stability of our results demonstrates that probably an adequate steroid therapeutical scheme is more useful than continuous steroid administration in the treatment of OLP.

Cyclosporin A mouthwash in the treatment of oral lichen planus

Seven patients with long-standing atrophic/erosive oral lichen planus were treated for 4 weeks with cyclosporin A as a mouthwash. At the end of the 3-month follow-up period, no improvement in disease status was noted in any of the patients, although two patients showed a slight improvement of their lesions at the end of 1 month of treatment. Cyclosporin A as a mouthwash does not seem to be an effective means of treating severe oral lichen planus.

Dramatic response to levamisole and low-dose prednisolone in 23 patients with oral lichen planus: a 6-year prospective follow-up study

The purpose of this prospective study was to evaluate the short-term and long-term clinical efficacy of levamisole used with low-dose prednisolone in patients with refractory oral lichen planus. Twenty-three patients with OLP who had been treated unsuccessfully with other modalities were given 150 mg/day levamisole and 15 mg/day prednisolone for 3 consecutive days each week. Twelve patients showed dramatic remission of signs and symptoms within 2 weeks, whereas 11 had partial remission. All 23 reported significant pain relief and showed no evidence of erosive oral lichen planus after 4 to 6 weeks of treatment. All 23 also remained free from symptoms for 6 to 9 months after the treatment ended. There were few side effects from this treatment besides minor skin rash, headache, and insomnia from the levamisole in three cases. We conclude that the addition of levamisole to prednisolone may produce improved results in the management of erosive oral lichen planus.

[Therapeutic management of oral lichen planus. Presentation of a representative case]

The authors describe the more efficient therapeutical plans of oral lichen planus, reducing the tendency to relapse.

Effectiveness of a low dose of cyclosporine in the management of patients with oral erosive lichen planus

This study investigated the effectiveness of a low-dose cyclosporine rinse used in the treatment of oral erosive lichen planus. Fourteen patients with oral erosive lichen planus provided seven experimental sites treated with cyclosporine and seven control sites treated with a placebo. Participants rinsed with 5 ml (500 mg) of cyclosporine or 5 ml of a placebo for 5 minutes each day over a period of 4 weeks. Cyclosporine blood levels as well as complete blood cell counts with differential and serial multiple analysis were monitored throughout the study. Weekly quantitative measurements of lesion size and character (ulceration, erythema, and reticulation) were recorded with the use of an intraoral grid. Healing was defined as the transition from ulceration to erythema to reticulation or to complete resolution. Pain assessment with the use of a visual analogue scale and a questionnaire pertaining to any side effects of treatment were completed each week. At 4 weeks, a statistically significant difference was observed in lesion healing between the cyclosporine and placebo groups. All experimental sites demonstrated progressive healing with evidence of reduced erythema and ulceration, increased reticulation, and decreased pain scores. In contrast, control sites exhibited minimal change in lesion size or character, and patients reported unchanged or increased pain scores. No significant side effects were reported. Within the parameters of this investigation, topical cyclosporine proved to an effective alternative therapy to currently available medications used in the treatment of oral lichen planus.

Photochemotherapy of oral lichen planus. A controlled study

Photochemotherapy with 8-methoxypsoralen and long-wave ultraviolet light (PUVA) has become a useful alternative in dermatologic therapy. PUVA therapy has been successfully used in the treatment of severe psoriasis and cutaneous lichen planus. The aim of this investigation was to use PUVA in the treatment of oral lichen planus (OLP). Eighteen patients with long-standing, bilateral, and severe OLP of the buccal mucosa participated in the investigation. A dose of 0.6 mg/kg 8-methoxypsoralen was administered orally 2 hours before long-wave ultraviolet light irradiation was done. The patients were randomly assigned to treatment of the left or right side of the buccal mucosa. The irradiation therapy was given 12 times at intervals of 2 to 3 days, and the patients received a total average dosage of 16.5 J/cm2. The results showed that 13 treated sites compared with six control sites responded significantly favorable to PUVA therapy. Two patients dropped out because of side effects that were similar to those seen after whole-body irradiation PUVA treatment. The follow up times was 12 months. The conclusion of this study is that PUVA seems to be effective in the treatment of OLP and should be considered in severe cases of OLP.

Cyclosporine A, an alternative to the oral lichen planus erosive treatment

We present a double-blind study in two groups afflicted with oral lichen planus erythematous of long evolution and resistant to other treatments. We tested on it a treatment with Cyclosporine A (CyA) which had been successfully used before by many dermatologists. In the group A we used mouthwashes with a 5 ml Cyclosporine A solution to a 10% in olive oil of 0.4 degrees of acidity for five minutes, three times a day for eight weeks. In the control group we used acetonide of triamcinolone 01% in aqueous solution. Patients in group A improved considerably in their symptomatology in a 90% against a 60% in group B. In group A we could appreciate a disappearance of the symptomatology after two weeks of treatment in 60% of patients against 30% in group B. CyA can be an alternative to the conventional treatments in the acute period of lichen planus although it can not be considered as a first option drug because of the high cost of the treatment. For long term, results are not so good and we consider that extensive studies are necessary.

The vulvovaginal-gingival syndrome of lichen planus. The clinical characteristics of 22 patients

BACKGROUND AND DESIGN

The vulvovaginal-gingival syndrome is a variant of mucosal lichen planus characterized by erosions and desquamation of the vulva, vagina, and gingiva. The clinical features of patients initially evaluated for vulvitis who exhibited the additional features of this syndrome have been described in one previous study. In the current study, 22 women with biopsy-proved oral lichen planus and clinical evidence of vulvovaginal lichen planus were examined and treated. This group of patients represents the largest reported series demonstrating the vulvovaginal-gingival syndrome.

RESULTS

Gingival lichen planus, present in all patients, was characterized by erosions and erythema in 16 subjects and by white, reticulated lesions in six others. Vulvovaginal lichen planus also displayed erosions in the majority of patients. The response to a wide variety of therapeutic agents was satisfactory in most patients. However, concomitant use of several drugs was usually required to achieve beneficial results.

CONCLUSIONS

Patients with oral lichen planus should be routinely examined for the presence of disease on other mucosal surfaces. The recognition of this syndrome, which is undoubtedly more common than previously reported, will avoid unnecessary delay in the treatment of these patients.

Cyclosporin A in an adhesive base for treatment of recalcitrant oral lichen planus. An open trial

Patients with symptomatic oral lichen planus often require therapy to reduce signs and symptoms of the condition. For this purpose, corticosteroids are frequently used. In this study the effect of another immunosuppressive drug, cyclosporin A was evaluated; it was applied as a topical drug four times daily and contained 0.025% cyclosporin A. The study group was composed of nine symptomatic patients in whom the diagnosis of oral lichen planus was confirmed by histopathologic examination including immunofluorescence. All patients had unsuccessfully undergone previous treatment with topical or systemic corticosteroids. The minimum follow-up period in the present study was at least 4 months. Four patients showed partial response to treatment with respect to signs and symptoms. None of the patients had a complete remission. Five patients showed no response or even complained of an increase of signs and symptoms. No adverse side effects of the drug were recorded during follow-up. Although the number of patients has been small, the results of this study indicate that topical application of cyclosporin A (0.025%) in the treatment of recalcitrant oral lichen planus does not offer a distinct advantage over the use of topical corticosteroids.

Double-blind clinical trial of 0.05% clobetasol propionate (corrected from proprionate) ointment in orabase and 0.05% fluocinonide ointment in orabase in the treatment of patients with oral vesiculoerosive diseases

Because of their chronic nature treatment of oral vesiculoerosive diseases remains a challenge to the oral medicine specialist. Even though oral vesiculoerosive diseases respond well to systemic steroids, adverse side effects sometimes limit their use. Potent topical steroids are becoming increasingly useful to treat these chronic conditions with good control. The purpose of this double-blind clinical trial was to compare clobetasol propionate and fluocinonide ointment in orabase as treatments for controlling oral vesiculoerosive diseases. Sixty patients were asked to participate (43 women and 17 men). Data are reported for 55 patients. Each patient was seen at baseline and at days 7, 14, 21, and 28. Variables evaluated were pain, erythema, atrophy, and size of lesion. Overall, both medications had a beneficial effect in the control of symptoms and signs of oral vesiculoerosive diseases with minimal side effects. Clobetasol propionate was better than fluocinonide as measured by more rapid control of pain (within 7 days). Candidiasis was observed in 13 patients at the end of treatment (most of them carriers of Candida). Therefore normal carriers should be identified and treatment with antifungal therapy instituted before the patient begins using topical steroids.

Oral lichen planus: a review

Lichen planus is a somewhat frequent oral lesion. The most prevalent type is reticular, which is asymptomatic. The erosive and atropic forms, although not as common, cause discomfort or pain, and the patient usually demands attention. Treatment modalities include the use of topical steroids, although retinoic acid, griseofulvin and cyclosporine have been used. The occurrence of squamous cell carcinoma in areas of lichen planus make it necessary to follow up on patients suffering from chronic lesions.