Oral lichen planus

Published on 18/03/2015 by admin

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Oral lichen planus

Drore Eisen

Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports

image

Oral lichen planus (OLP) is a common chronic inflammatory disorder which rarely undergoes complete remission even with treatment.

Management strategy

All treatment should be aimed at eliminating erythematous and ulcerative lesions, alleviating symptoms, and potentially reducing the risk of malignant transformation. Given the uncertainty of the premalignant nature of OLP, it is important to monitor all patients carefully and long term.

Although the etiology of OLP is unknown, the possibility of a hypersensitivity reaction (oral lichenoid reaction, OLR) should be considered when lesions are confined to mucosa in close proximity to a dental restoration. In such cases, identifying allergies to dental materials by patch testing, and then removing the fillings with positive reactions, or empirically removing the filling, often results in resolution of lesions. Another uncommon cause of OLR is drugs. A thorough medication history, with emphasis on NSAIDs, ACE inhibitors, oral hypoglycemics, antimalarials, and others is warranted, as drug-induced reactions are reversible when the implicated drug is withdrawn.

Eliminating exacerbating factors, including sharp dental restorations, fractured teeth, and poorly fitting dental appliances, should be attempted before medical therapy is initiated. An optimal oral hygiene program that eliminates dental plaque and calculus also significantly improves gingival OLP.

All agents used for the treatment of OLP are for off-label indications and lack adequate efficacy studies; thus, optimal dose, duration of treatment, safety, and their true efficacy remain unknown.

The most useful agents for the treatment of symptomatic OLP are potent topical corticosteroids (i.e., fluocinonide or clobetasol). Asymptomatic reticular lesions do not require therapy. For gingival OLP, custom dental trays that cover the teeth are filled with topical corticosteroids and worn for prolonged periods. For intractable erosive lesions, intralesional triamcinolone acetonide (10–20 mg/mL) repeated every 2 to 4 weeks is highly effective.

Unresponsive OLP may benefit from topical immunomodulators (i.e., tacrolimus, pimecrolimus, and cyclosporine) which may be used as alternatives to, or in conjunction with, topical corticosteroids. Burning and stinging are the most frequent adverse effects, and relapses after cessation of therapy are to be expected. Given the potential increased risk of cancer with these immunosuppressants, their long-term use for this chronic, potentially premalignant disease may be limited.

A number of herbal preparations have been reported to benefit OLP. These include purslane (235 mg/day), curcuminoids (6000 mg/day), lycopene (8 mg/day), and topical aloe vera (70% concentration).

A variety of lasers have also been shown to be beneficial in alleviating OLP symptoms.

For patients with severe oral disease or with extraoral manifestations, the addition of systemic immunosuppressives is indicated. The author has found that methotrexate (12.5–20 mg/week), azathioprine (100–150 mg/day), mycophenolate mofetil (1–2 g/day), acitretin (25–50 mg/day), and hydroxychloroquine (400 mg/day) are the most useful systemic agents. Cyclosporine, thalidomide, and TNF-α inhibitors may be used for refractory cases, but data are limited.

Systemic corticosteroids (30–80 mg of prednisone) should be reserved for acute flares and not as maintenance therapy. Secondary candidiasis frequently complicates all therapy and requires treatment with topical or systemic agents. All treatments for OLP are palliative and not curative, and patients should expect a chronic course with intermittent acute exacerbations.

Specific investigations

First-line therapies

imageTopical corticosteroids B
imageIntralesional corticosteroids B

Second-line therapies

Topical immunosuppressants
imageTacrolimus A
imagePimecrolimus A
imageCyclosporine A
Systemic immunosuppressants
imageMethotrexate E
imageMycophenolate mofetil E
imageAzathioprine E
imageHydroxychloroquine sulfate C
imageTNF-α inhibitors (adalimumab, etanercept) E
imageLevamisole C

image

Third-line therapies

imageTopical and systemic retinoids B
imageSystemic cyclosporine D
imageThalidomide E
imagePurslane B
imageCurcuminoids C
imageLycopene C
imageAloe vera gel B
imageLaser B

[/level-membership-for-dermatology-category][not-level-membership-for-dermatology-category]

Oral lichen planus

Drore Eisen

Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports

image

Oral lichen planus (OLP) is a common chronic inflammatory disorder which rarely undergoes complete remission even with treatment.

Management strategy

All treatment should be aimed at eliminating erythematous and ulcerative lesions, alleviating symptoms, and potentially reducing the risk of malignant transformation. Given the uncertainty of the premalignant nature of OLP, it is important to monitor all patients carefully and long term.

Although the etiology of OLP is unknown, the possibility of a hypersensitivity reaction (oral lichenoid reaction, OLR) should be considered when lesions are confined to mucosa in close proximity to a dental restoration. In such cases, identifying allergies to dental materials by patch testing, and then removing the fillings with positive reactions, or empirically removing the filling, often results in resolution of lesions. Another uncommon cause of OLR is drugs. A thorough medication history, with emphasis on NSAIDs, ACE inhibitors, oral hypoglycemics, antimalarials, and others is warranted, as drug-induced reactions are reversible when the implicated drug is withdrawn.

Eliminating exacerbating factors, including sharp dental restorations, fractured teeth, and poorly fitting dental appliances, should be attempted before medical therapy is initiated. An optimal oral hygiene program that eliminates dental plaque and calculus also significantly improves gingival OLP.

All agents used for the treatment of OLP are for off-label indications and lack adequate efficacy studies; thus, optimal dose, duration of treatment, safety, and their true efficacy remain unknown.

The most useful agents for the treatment of symptomatic OLP are potent topical corticosteroids (i.e., fluocinonide or clobetasol). Asymptomatic reticular lesions do not require therapy. For gingival OLP, custom dental trays that cover the teeth are filled with topical corticosteroids and worn for prolonged periods. For intractable erosive lesions, intralesional triamcinolone acetonide (10–20 mg/mL) repeated every 2 to 4 weeks is highly effective.

Unresponsive OLP may benefit from topical immunomodulators (i.e., tacrolimus, pimecrolimus, and cyclosporine) which may be used as alternatives to, or in conjunction with, topical corticosteroids. Burning and stinging are the most frequent adverse effects, and relapses after cessation of therapy are to be expected. Given the potential increased risk of cancer with these immunosuppressants, their long-term use for this chronic, potentially premalignant disease may be limited.

A number of herbal preparations have been reported to benefit OLP. These include purslane (235 mg/day), curcuminoids (6000 mg/day), lycopene (8 mg/day), and topical aloe vera (70% concentration).

A variety of lasers have also been shown to be beneficial in alleviating OLP symptoms.

For patients with severe oral disease or with extraoral manifestations, the addition of systemic immunosuppressives is indicated. The author has found that methotrexate (12.5–20 mg/week), azathioprine (100–150 mg/day), mycophenolate mofetil (1–2 g/day), acitretin (25–50 mg/day), and hydroxychloroquine (400 mg/day) are the most useful systemic agents. Cyclosporine, thalidomide, and TNF-α inhibitors may be used for refractory cases, but data are limited.

Systemic corticosteroids (30–80 mg of prednisone) should be reserved for acute flares and not as maintenance therapy. Secondary candidiasis frequently complicates all therapy and requires treatment with topical or systemic agents. All treatments for OLP are palliative and not curative, and patients should expect a chronic course with intermittent acute exacerbations.

Specific investigations

First-line therapies

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imageTopical corticosteroids B