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

Therapeutic strategies for oral lichen planus: State of the art and new insights

Oral lichen planus (OLP) is a chronic inflammatory disease of the oral mucosa. Several clinical subtypes of OLP have been reported, including the reticular and erosive one. On the one hand, reticular OLP is usually asymptomatic and is characterized by white streaks surrounded by well-defined erythematous borders. On the other hand, erosive OLP shows ulcerations and erosions surrounded by erythematous mucosa. While reticular OLP is relatively easy to control, erosive OLP is extremely painful and refractory to therapies, limiting the quality of life of the patients. In addition, treating erosive OLP is extremely tricky, and a gold standard treatment has not yet been established. However, several therapeutic approaches have been reported as effective, including systemic corticosteroids, systemic retinoids, and anti-interleukin (IL)-17/anti-IL-23 drugs. Indeed, our group and other several authors reported the effectiveness of anti-IL17, anti-IL12/23, and anti-IL23 agents in refractory OLP, highlighting the urgency of clinical studies on the use of anti-IL agents in OLP patients. In this paper, we reviewed the English- and German-language literature about therapeutic strategies for treating OLP, focusing on new systemic therapies for erosive OLP.

Oral lichen planus: comparative efficacy and treatment costs-a systematic review

Objective

To compare the reported efficacy and costs of available interventions used for the management of oral lichen planus (OLP).

Materials and methods

A systematic literature search was performed from database inception until March 2021 in MEDLINE via PubMed and the Cochrane library following PRISMA guidelines. Only randomized controlled trials (RCT) comparing an active intervention with placebo or different active interventions for OLP management were considered.

Results

Seventy (70) RCTs were included. The majority of evidence suggested efficacy of topical steroids (dexamethasone, clobetasol, fluocinonide, triamcinolone), topical calcineurin inhibitors (tacrolimus, pimecrolimus, cyclosporine), topical retinoids, intra-lesional triamcinolone, aloe-vera gel, photodynamic therapy, and low-level laser therapies for OLP management. Based on the estimated cost per month and evidence for efficacy and side-effects, topical steroids (fluocinonide > dexamethasone > clobetasol > triamcinolone) appear to be more cost-effective than topical calcineurin inhibitors (tacrolimus > pimecrolimus > cyclosporine) followed by intra-lesional triamcinolone.

Conclusion

Of common treatment regimens for OLP, topical steroids appear to be the most economical and efficacious option followed by topical calcineurin inhibitors. Large-scale multi-modality, prospective trials in which head-to-head comparisons interventions are compared are required to definitely assess the cost-effectiveness of OLP treatments.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-022-02168-4.

Topical Cyclosporine in Oral Lichen Planus-A Series of 21 Open-Label, Biphasic, Single-Patient Observations

Topical cyclosporine (CSA) has been reported as an alternative treatment in steroid-refractory oral lichen planus (OLP), but evidence is limited and conflicting. An N-of-1 trial setting could be appropriate to evaluate interindividual differences in treatment response. We studied a series of 21 open-label, biphasic single-patient observations. Patients (15 women, 6 men) with OLP recalcitrant to topical steroids received four weeks of CSA mouth rinse (200 mg/twice daily) followed by four weeks of drug withdrawal. Pain (visual analogue scale (VAS) score), disease extent (physicians’ global assessment (PGA) score) and quality of life (Dermatology Life Quality Index (DLQI) score,) were assessed at baseline (T0), after four weeks of treatment (T1) and after another four weeks without treatment (T2). Median age was 58 years (interquartile range/IQR = 52–67) and median disease duration was 18 months (IQR = 12–44). Median baseline VAS score decreased significantly at T1 (p = 0.0003) and increased at T2 (p = 0.032) (T0 = 5 (IQR = 3–6.5); T1 = 2 (IQR = 0.5–3.4); T2 = 3 (IQR = 2–4.8)). Similarly, median baseline PGA score decreased significantly at T1 (p = 0.001) and increased at T2 (p = 0.007) (T0 = 2 (IQR = 1.3–2.5); T1 = 1 (IQR = 1–2); T2 = 2 (IQR = 1–2)). Median baseline DLQI score also decreased significantly at T1 (p =.027) but did not change at T2 (p = 0.5) (T0 = 2.5 (IQR = 1–5.8); T1 = 1 (IQR = 0–3); T2 = 1 (IQR = 1–4)). CSA responders (n = 16) had significantly higher median baseline VAS scores (5.2 (IQR = 5–6.5)) than nonresponders (n =5) (2 (IQR = 2–3.5) (p = 0.02). In our study, pain, disease extent and quality of life of patients with OLP improved significantly during therapy with low-dose CSA mouth rinse and exacerbated after drug withdrawal. Remarkably, patients with high initial VAS scores seemed to profit most.

Interventions for treating oral lichen planus: corticosteroid therapies

BACKGROUND

Oral lichen planus (OLP) is a relatively common chronic T cell-mediated disease, which can cause significant pain, particularly in its erosive or ulcerative forms. As pain is the indication for treatment of OLP, pain resolution is the primary outcome for this review. This review is an update of a version last published in 2011, but focuses on the evidence for corticosteroid treatment only. A second review considering non-corticosteroid treatments is in progress.

OBJECTIVES

To assess the effects and safety of corticosteroids, in any formulation, for treating people with symptoms of oral lichen planus.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases to 25 February 2019: Cochrane Oral Health's Trials Register, CENTRAL (2019, Issue 1), MEDLINE Ovid, and Embase Ovid. ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. There were no restrictions on language or date of publication.

SELECTION CRITERIA

We considered randomised controlled clinical trials (RCTs) of any local or systemic corticosteroid treatment compared with a placebo, a calcineurin inhibitor, another corticosteroid, any other local or systemic (or both) drug, or the same corticosteroid plus an adjunctive treatment.

DATA COLLECTION AND ANALYSIS

Three review authors independently scanned the titles and abstracts of all reports identified, and assessed risk of bias using the Cochrane tool and extracted data from included studies. For dichotomous outcomes, we expressed the estimates of effects of an intervention as risk ratios (RR), with 95% confidence intervals (CI). For continuous outcomes, we used mean differences (MD) and 95% CI. The statistical unit of analysis was the participant. We conducted meta-analyses only with studies of similar comparisons reporting the same outcome measures. We assessed the overall certainty of the evidence using GRADE.

MAIN RESULTS

We included 35 studies (1474 participants) in this review. We assessed seven studies at low risk of bias overall, 11 at unclear and the remaining 17 studies at high risk of bias. We present results for our main outcomes, pain and clinical resolution measured at the end of the treatment course (between one week and six months), and adverse effects. The limited evidence available for comparisons between different corticosteroids, and corticosteroids versus alternative or adjunctive treatments is presented in the full review. Corticosteroids versus placebo Three studies evaluated the effectiveness and safety of topical corticosteroids in an adhesive base compared to placebo. We were able to combine two studies in meta-analyses, one evaluating clobetasol propionate and the other flucinonide. We found low-certainty evidence that pain may be more likely to be resolved when using a topical corticosteroid rather than a placebo (RR 1.91, 95% CI 1.08 to 3.36; 2 studies, 72 participants; I² = 0%). The results for clinical effect of treatment and adverse effects were inconclusive (clinical resolution: RR 6.00, 95% CI 0.76 to 47.58; 2 studies, 72 participants; I² = 0%; very low-certainty evidence; adverse effects RR 1.48, 95% 0.48 to 4.56; 3 studies, 88 participants, I² = 0%, very low-certainty evidence). Corticosteroids versus calcineurin inhibitors Three studies compared topical clobetasol propionate versus topical tacrolimus. We found very low-certainty evidence regarding any difference between tacrolimus and clobetasol for the outcomes pain resolution (RR 0.45, 95% CI 0.24 to 0.88; 2 studies, 100 participants; I² = 80%), clinical resolution (RR 0.61, 95% CI 0.38 to 0.99; 2 studies, 52 participants; I² = 95%) and adverse effects (RR 0.05, 95% CI 0.00 to 0.83; 2 studies, 100 participants; very low-certainty evidence) . One study (39 participants) compared topical clobetasol and ciclosporin, and provided only very low-certainty evidence regarding the rate of clinical resolution with clobetasol (RR 3.16, 95% CI 1.00 to 9.93), pain resolution (RR 2.11, 95% CI 0.76 to 5.86) and adverse effects (RR 6.32, 95% CI 0.84 to 47.69). Two studies (60 participants) that compared triamcinolone and tacrolimus found uncertain evidence regarding the rate of clinical resolution (RR 0.86, 95% CI 0.55 to 1.35; very low-certainty evidence) and that there may be a lower rate of adverse effects in the triamcinolone group (RR 0.47, 95% CI 0.22 to 0.99; low-certainty evidence). These studies did not report on pain resolution.

AUTHORS' CONCLUSIONS

Corticosteroids have been first line for the treatment of OLP. This review found that these drugs, delivered topically as adhesive gels or similar preparations, may be more effective than placebo for reducing the pain of symptomatic OLP; however, with the small number of studies and participants, our confidence in the reliability of this finding is low. The results for clinical response were inconclusive, and we are uncertain about adverse effects. Very low-certainty evidence suggests that calcineurin inhibitors, specifically tacrolimus, may be more effective at resolving pain than corticosteroids, although there is some uncertainty about adverse effects and clinical response to tacrolimus showed conflicting results.

Could photodynamic therapy be utilized as a treatment modality for oral lichen planus?

BACKGROUND

Oral lichen planus (OLP) is a chronic inflammatory disease. There is no standard treatment modality for OLP. Recently, photodynamic therapy (PDT) has been advocated as a new treatment modality for OLP.

AIM

The aim of the present study is to compare the effect of PDT using methylene blue (MB) as a photosensitizer to the effect of topical corticosteroids in the treatment of erosive OLP lesions.

MATERIALS AND METHODS

Our study included 20 patients with erosive OLP. Patients were divided into two groups. The study group included 10 patents which received MB-PDT. Patients were instructed to use MB as mouth path for 5 min. After 10 min, we applied focal red light on OLP lesions (wavelength 660 nm, Intensity 100-130 m W/cm2) for 2 min. The PDT was applied twice a week for four weeks. In the control group, 10 patients were instructed to apply topical betamethasone valerate ointment 100 mg on OLP lesion three times per day for four weeks. Subjective, objective scores and lesion size were recorded at time zero, after 2 weeks and after 4 weeks from the start of treatments.

RESULTS

Both groups showed statistically significant differences between time zero and the 4^th week of treatment in subjective, objective scores and the area of the lesions. MB-PDT showed a higher degree of improvement than topical corticosteroids between time zero and the 4^th week of treatment.

CONCLUSION

Photodynamic therapy can be used as a treatment for erosive OLP. PDT offers improvement of OLP subjective and objective scores without major side effects.

Interventions for the management of oral lichen planus: a review of the conventional and novel therapies

OBJECTIVE

This narrative review focuses on the rationale and role of conventional and newer therapies in the management of oral lichen planus (OLP) with emphasis on randomized controlled trials (RCTs) reported over two decades.

MATERIALS AND METHODS

Literature search was conducted to identify RCTs for the management of OLP from 1 January 1995 to 31 December 2015; Medline and Cochrane databases complemented with manual search were used. Primary outcome as resolution of pain was evaluated with the analysis of clinical resolution of erythema and ulceration as secondary outcome.

RESULTS

The search provided 260 abstracts, of which 70 full-text articles were included. Majority of trials used topical steroids with very few trials on newer therapies. It was found that topical steroids are effective for symptomatic management of OLP with equal efficacy shown by topical calcineurin inhibitors and retinoids. However, the side effect of transient burning sensation with relapse was more with calcineurin inhibitors.

CONCLUSION

Although the newer therapies offer advantage over steroids for the management of OLP in recalcitrant cases, extensive lesions, and cases unresponsive to steroids, but sufficient clinical data on their use are still lacking. Hence, more RCTs with large sample size, adequate treatment duration, and long-term follow-up are required for clinical utility.

Possible alternative therapies for oral lichen planus cases refractory to steroid therapies

Oral lichen planus (OLP) is a chronic inflammatory disorder with a multifactorial etiopathogenesis. Immune dysregulation plays a critical role in the development and progression of this disease. Patients' lives may be affected by pain caused by atrophic-erosive lesions. Given the obscure etiology, treatment is usually symptomatic. Topical steroids remain the mainstay of management. However, their therapeutic benefits are not always evident. There are substantial data on the possible therapeutic strategies that are effective in OLP cases refractory to steroids. This review provides an overview of the current approaches for the management of steroid-refractory OLP. The miscellaneous treatment regimens include tacrolimus, pimecrolimus, thalidomide, low-level laser therapy, photodynamic therapy, and surgical excision. Some results obtained from these studies were promising. However, further studies, especially randomized controlled trials with strict inclusion and exclusion criteria and larger sample sizes, are required for the evaluation of the long-term safety and efficacy of these therapies.

Tacrolimus 0.03% ointment in labial discoid lupus erythematosus: A randomized, controlled clinical trial

In this randomized, controlled clinical trial to compare efficacy and safety, 41 patients with labial discoid lupus erythematosus (DLE) were randomized to 2 groups, either receiving tacrolimus 0.03% ointment (n = 22) or triamcinolone acetonide 0.1% cream (n = 19). Each patient was treated with 3, 2, and 1 daily doses in the first, second, and third weeks, respectively, for 1 course. After the 3 week treatment, patients with complete disappearance of erosion were followed up for 3 months. After the 3 week application, 20 participants in the tacrolimus group and 19 in the triamcinolone acetonide group completed the study. The rates of complete response were 70% and 89.5% in tacrolimus-treated and triamcinolone acetonide-treated patients, respectively, with no significant difference (P = .235). Reduction in erosion and erythema showed no significant difference between groups (P > .05). Final reduction in reticulation areas and numeric rating scale scores were significantly greater in the tacrolimus group than in the triamcinolone acetonide group (P = .013; P = .048, respectively). Only 1 patient receiving tacrolimus presented with slight discomfort. There was no significant difference in 3 month recurrence rate between the groups (P > .05). Topical tacrolimus is considered as effective as triamcinolone acetonide for the management of labial DLE.

Disease scoring systems for oral lichen planus; a critical appraisal

The aim of the present study has been to critically review 22 disease scoring systems (DSSs) on oral lichen planus (OLP) that have been reported in the literature during the past decades. Although the presently available DSSs may all have some merit, particularly for research purposes, the diversity of both the objective and subjective parameters used in these systems and the lack of acceptance of one of these systems for uniform use, there is a need for an international, authorized consensus meeting on this subject. Because of the natural course of OLP characterized by remissions and exacerbations and also due to the varying distribution pattern and the varying clinical types, e.g. reticular and erosive, the relevance of a DSS based on morphologic parameters is somewhat questionable. Instead, one may consider to only look for a quality of life scoring system adapted for use in OLP patients.

Oral lichen planus: REU scoring system correlates with pain

OBJECTIVES

The objectives of this study were to correlate a semiquantitative scoring system for oral lichen planus (OLP) with pain before versus after treatment and to analyze sites of involvement and candidal status of patients in a retrospective study.

STUDY DESIGN

Reticulation/keratosis, erythema, and ulceration (REU) scores and numerical rating scale (NRS) for pain were used. Correlation was tested using Spearman rank correlation, and the change in REU and NRS scores using the paired t test.

RESULTS

One hundred fifteen patients were evaluable with 55 follow-up visits. Pain showed positive correlation with the total weighted score (r = .40), erythema (r = .35), ulceration (r = .31), and reticulation scores (r = .29), all at P < .005. There was improvement in REU and NRS scores before versus after treatment (P < .0001). The internal consistency reliability analysis yielded good reliability with Cronbach coefficient alpha of 0.70. The ventral tongue, floor of mouth, and soft palate were never the only sites affected. Candidal carriage was present in 24% of cases but candidiasis developed in only 10% of carriers.

CONCLUSIONS

The REU system is easy to use, correlates with an NRS for pain, and reliably reflects improvement attributable to treatment. Ventral tongue, floor of mouth, and soft palate were sites of OLP only if other sites were involved and candidiasis did not always develop in patients who were carriers.

Interventions for treating oral lichen planus

BACKGROUND

Oral lichen planus (OLP) is a common chronic autoimmune disease associated with cell-mediated immunological dysfunction. Symptomatic OLP is painful and complete healing is rare.

OBJECTIVES

To assess the effectiveness and safety of any form of therapy for symptomatic OLP.

SEARCH STRATEGY

The following electronic databases were searched: the Cochrane Oral Health Group Trials Register (to 26 January 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 1), MEDLINE via OVID (1950 to 26 January 2011) and EMBASE via OVID (1980 to 26 January 2011). There were no restrictions regarding language or date of publication.

SELECTION CRITERIA

All randomised controlled clinical trials (RCTs) of therapy for symptomatic OLP which compared treatment with a placebo or between treatments or no intervention were considered in this review.

DATA COLLECTION AND ANALYSIS

The titles and abstracts of all reports identified were scanned independently by two review authors. All studies meeting the inclusion criteria were assessed for risk of bias and data were extracted. For dichotomous outcomes, the estimates of effects of an intervention were expressed as risk ratios (RR) together with 95% confidence intervals. For continuous outcomes, mean differences (MD) and 95% confidence intervals were used to summarise the data for each group. The statistical unit was the patient. Meta-analyses were done only with studies of similar comparisons reporting the same outcome measures.

MAIN RESULTS

28 trials were included in this review. Pain is the primary outcome of this review because it is the indication for treatment of OLP, and therefore this review indicates as effective, only those treatments which significantly reduce pain. Although topical steroids are considered first line treatment for symptomatic OLP, we identified no RCTs that compared steroids with placebo. There is no evidence from the three trials of pimecrolimus that this treatment is better than placebo in reducing pain from OLP. There is weak evidence from two trials, at unclear and high risk of bias respectively, that aloe vera may be associated with a reduction in pain compared to placebo, but it was not possible to pool the pain data from these trials. There is weak and unreliable evidence from two small trials, at high risk of bias, that cyclosporin may reduce pain and clinical signs of OLP, but meta-analysis of these trials was not possible.There were five trials that compared steroids with calcineurin inhibitors, each evaluating a different pair of interventions. There is no evidence from these trials that there is a difference between treatment with steroids compared to calcineurin inhibitors with regard to reducing pain associated with OLP. From six trials there is no evidence that any specific steroid therapy is more or less effective at reducing pain compared to another type or dose of steroid.

AUTHORS' CONCLUSIONS

Although topical steroids are considered to be first line treatment, we identified no RCTs that compared steroids with placebo in patients with symptomatic OLP. From the trials in this review there is no evidence that one steroid is any more effective than another. There is weak evidence that aloe vera may reduce the pain of OLP and improve the clinical signs of disease compared to placebo. There is weak and unreliable evidence that cyclosporin may reduce pain and clinical signs of OLP. There is no evidence that other calcineurin inhibitors reduce pain compared to either steroids or placebo. From the 28 trials included in this systematic review, the wide range of interventions compared means there is insufficient evidence to support the effectiveness of any specific treatment as being superior.

Topical immunomodulators for management of oral mucosal conditions, a systematic review; part I: calcineurin inhibitors

IMPORTANCE OF THE FIELD

Topical immunomodulators have been used for the management of oral mucosal diseases. Topical immunomodulating preparations may have utility in local management of oral disease which is resistant to topical steroids and oral findings of an immunologic-mediated systemic disease with primary or persisting, oral mucosal involvement.

AREAS COVERED IN THIS REVIEW

This paper is the first part of a systematic review of topical immunomodulators for the management of various oral indications focused on calcineurin inhibitors. The literature search revealed that data are available for cyclosporine, tacrolimus and pimecrolimus. In addition to the review of scientific evidence, this paper presents the potential market, the mechanism of action, the competitive environment and future development options.

WHAT THE READER WILL GAIN

The reader will find weighted conclusions for the topical use of the calcineurin inhibitors in the management of oral diseases.

TAKE HOME MESSAGE

Topical calcineurin inhibitors may be useful as a second-line treatment in several oral diseases, particularly oral lichen planus.

Pimecrolimus 1% cream for oral erosive lichen planus: a 6-week randomized, double-blind, vehicle-controlled study with a 6-week open-label extension to assess efficacy and safety

OBJECTIVE

To assess the efficacy and safety of topical pimecrolimus 1% cream in the treatment of oral erosive lichen planus.

DESIGN

A 6-week randomized, double-blind, vehicle-controlled phase followed by a 6-week open-label phase.

SETTING

Outpatients of the Department of Dermatology, University of Utah.

PATIENTS

Twenty-one patients with oral erosive lichen planus were randomized and treated with either pimecrolimus 1% cream or vehicle cream.

INTERVENTION

Pimecrolimus 1% cream, or its vehicle, were applied twice daily for 6 weeks to each side of the mouth with a 2×2 inch gauze pad folded in half and placed directly on the erosive lesion.

MAIN OUTCOME MEASURES

Efficacy was based on clinical evaluation of Investigator's Global Assessment (IGA) of the overall severity of the disease, erythema, measurement of the size of any target erosion in millimetres, and assessment of spontaneous pain. Blood levels of pimecrolimus were monitored in all subjects on day 0 and repeated on day 7.

RESULTS

Pimecrolimus 1% cream was superior to vehicle cream in reducing mean IGA, pain, and erosion size. For the vehicle group that entered the open-label phase, pimecrolimus 1% cream improved the mean IGA, pain, erosion size, and erythema. Pimecrolimus levels were detected in nine out of 10 of the pimecrolimus-treated subjects. These levels were consistently low. The pimecrolimus cream was well-tolerated. No clinically relevant, drug-related adverse events were reported.

CONCLUSION

Pimecrolimus 1% cream was superior to vehicle in reducing pain, erythema, decreasing erosion size, and improving overall severity of disease when compared with vehicle treatment.

Oral lichen planus and lichenoid reactions: etiopathogenesis, diagnosis, management and malignant transformation

Lichen planus, a chronic autoimmune, mucocutaneous disease affects the oral mucosa (oral lichen planus or OLP) besides the skin, genital mucosa, scalp and nails. An immune mediated pathogenesis is recognized in lichen planus although the exact etiology is unknown. The disease most commonly affects middle-aged females. Oral lichenoid reactions (OLR) which are considered variants of OLP, may be regarded as a disease by itself or as an exacerbation of an existing OLP, by the presence of medication (lichenoid drug reactions) or dental materials (contact hypersensitivity). OLP usually presents as white striations (Wickham's striae), white papules, white plaque, erythema, erosions or blisters. Diagnosis of OLP is established either by clinical examination only or by clinical examination with histopathologic confirmation. Direct immunofluorescence examination is only used as an adjunct to the above method of diagnosis and to rule out specific autoimmune diseases such as pemphigus and pemphigoid. Histopathologic features of OLP and OLR are similar with suggestions of certain discriminatory features by some authors. Topical corticosteroids are the treatment of choice for OLP although several other medications have been studied including retinoids, tacrolimus, cyclosporine and photodynamic therapy. Certain OLP undergo malignant transformation and the exact incidence and mechanisms are still controversial. In this paper, etiopathogenesis, diagnosis, management and malignant transformation of OLP and OLR have been reviewed.

A randomized-controlled trial to compare topical cyclosporin with triamcinolone acetonide for the treatment of oral lichen planus

BACKGROUND

Various treatments have been employed to treat symptomatic oral lichen planus (OLP), but a complete cure is very difficult to achieve because of its recalcitrant nature. Topical cyclosporin therapy of OLP has shown conflicting results in many reports. The purpose of this study was to compare the effectiveness of cyclosporin solution with triamcinolone acetonide 0.1% in orabase in the treatment of Thai patients with OLP.

METHODS

Thirteen Thai patients with symptomatic OLP and proven by biopsy were randomly assigned treatment with cyclosporin (six) or triamcinolone acetonide 0.1% (seven). The patients were instructed to apply cyclosporin or triamcinolone acetonide 0.1% three times daily at the marker lesions and affected areas. The assessments were at weeks 0, 2, 4, 8 by clinical scoring and grid measurement of the target lesions. Cyclosporin levels were assessed at weeks 2 and 8 of treatment. Pain and burning sensation were evaluated by linear visual analogue scale (0-10).

RESULTS

OLP patients in the triamcinolone acetonide group showed equal cases of clinical complete and partial remission (50%). Whereas, in the cyclosporin group, there was partial remission in only two cases (33.5%) and no response in four cases (66.7%). However, our study showed that there were no statistical differences in pain, burning sensation and clinical response in OLP patients between the two groups (P > 0.01). Moreover, five of six cases in the cyclosporin group developed side-effects such as transient burning sensation, itching, swelling lips, petechial haemorrhages and others.

CONCLUSION

Our results indicated that topical cyclosporin did not provide any beneficial effect and was not more effective than triamcinolone acetonide 0.1% in the treatment of Thai patients with symptomatic OLP.

Oral lichen planus and oral lichenoid lesions: diagnostic and therapeutic considerations

Several therapeutic agents have been investigated for the treatment of oral lichen planus (OLP). Among these are corticosteroids, retinoids, cyclosporine, and phototherapy, in addition to other treatment modalities. A systematic review of clinical trials showed that particularly topical corticosteroids are often effective in the management of symptomatic OLP lichen planus. Systemic corticosteroids should be only considered for severe widespread OLP and for lichen planus involving other mucocutaneous sites. Because of the ongoing controversy in the literature about the possible premalignant character of OLP, periodic follow-up is recommended. There is a spectrum of oral lichen planus-like ("lichenoid") lesions that may confuse the differential diagnosis. These include lichenoid contact lesions, lichenoid drug reactions and lichenoid lesions of graft-versus-host disease. In regard to the approach to oral lichenoid contact lesions the value of patch testing remains controversial. Confirmation of the diagnosis of an oral lichenoid drug reaction may be difficult, since empiric withdrawal of the suspected drug and/or its substitution by an alternative agent may be complicated. Oral lichenoid lesions of graft-versus-host disease (OLL-GVHD) are recognized to have an association with malignancy. Local therapy for these lesions rests in topical agents, predominantly corticosteroids.

Ciclosporin vs. clobetasol in the topical management of atrophic and erosive oral lichen planus: a double-blind, randomized controlled trial

BACKGROUND

Oral lichen planus (OLP) is a chronic inflammatory disease that can be painful, especially in the atrophic and erosive forms. Several drugs have been used with varying results, but most treatments are empirical, and do not have adequate control groups or correct study designs.

OBJECTIVES

To compare the effectiveness of clobetasol and ciclosporin in the topical management of OLP and to evaluate which is more cost-effective and which gives the longest remission from signs and symptoms.

METHODS

A randomized, comparative, double-blind study was designed. Forty consecutive patients were divided into two groups to receive clobetasol propionate or ciclosporin for 2 months. Both drugs were placed in 4% hydroxyethyl cellulose bioadhesive gel. Antimycotic prophylaxis was also given. After the end of therapy, patients underwent a 2-month follow-up.

RESULTS

Eighteen of 19 clobetasol-treated patients (95%) improved after 2 months of therapy, while 13 of 20 ciclosporin-treated patients (65%) had a clinical response (P = 0.04). Symptomatology improved in 18 clobetasol-treated patients (95%) and in 17 ciclosporin-treated patients (85%) (not statistically significantly different). Two months after the end of therapy, 33% of clobetasol-treated patients and 77% of ciclosporin-treated patients were stable (P = 0.04). Clobetasol produced significantly more side-effects than ciclosporin (P = 0.04). The daily cost of ciclosporin treatment was 1.82 compared with 0.35 for clobetasol therapy.

CONCLUSIONS

Clobetasol is more effective than ciclosporin in inducing clinical improvement, but the two drugs have comparable effects on symptoms. Conversely, clobetasol gives less stable results than ciclosporin when therapy ends and has shown a higher incidence of side-effects. The daily cost of ciclosporin is more than five times higher than clobetasol.

A randomized controlled trial to compare steroid with cyclosporine for the topical treatment of oral lichen planus

OBJECTIVE

To compare the effectiveness of cyclosporine solution versus triamcinolone acetonide in orabase in the treatment of oral lichen planus (OLP) in reducing signs and symptoms.

STUDY DESIGN

One hundred thirty-nine biopsy-proven OLP patients were randomly assigned to cyclosporine (68) or steroid (71) applied onto the target lesion and affected areas. Assessments were at weeks 0, 2, 4, 8 by clinical scoring and grid measurement of the target lesion (reticulation, erythema, ulceration). Patients ranked severity of pain and burning sensation using visual analog scales.

RESULTS

Although clinical response, pain, burning sensation, area of reticulation, erythema, and ulceration at week 4 were all worse in patients receiving cyclosporine than in those receiving steroid, the differences were not statistically significant. Large patient-to-patient variability was evident over the observation period, with little evidence of marked changes in levels over time in both treatment groups.

CONCLUSION

Topical cyclosporine appears no more effective than steroid in the treatment of oral lichen planus.

Scoring system for monitoring oral lichenoid lesions: a preliminary study

BACKGROUND

Currently, there is no universal system for scoring the severity of lichenoid lesions of the oral cavity that is easy to use, reproducible and that is representative of the different clinical forms of the disease.

OBJECTIVES

In this study, a scoring system was developed to monitor the severity of oral lichen planus (OLP) and chronic oral graft-versus-host disease (cGVHD).

METHODS

Six patients with OLP and three with cGVHD were studied. This scoring system was utilized to compare the severity of disease within and between patients. Three investigators independently reviewed photographs taken from each patient and scored the severity of disease. Inter and intra-observer consistency was evaluated using the Spearman rank correlation analyses.

RESULTS

Intra-observer reliability was 0.98 (Spearman correlation coefficient) and inter-observer reliability was 1.00.

CONCLUSION

This scoring system is easy-to-use, reproducible, representative of the severity of the disease and useful for monitoring OLP and cGVHD.

Current controversies in oral lichen planus: report of an international consensus meeting. Part 2. Clinical management and malignant transformation

Despite recent advances in understanding the immunopathogenesis of oral lichen planus (LP), the initial triggers of lesion formation and the essential pathogenic pathways are unknown. It is therefore not surprising that the clinical management of oral LP poses considerable difficulties to the dermatologist and the oral physician. A consensus meeting was held in France in March 2003 to discuss the most controversial aspects of oral LP. Part 1 of the meeting report focused on (1) the relationship between oral LP and viral infection, with special emphasis on hepatitis C virus (HCV), and (2) oral LP pathogenesis, in particular the immune mechanisms resulting in lymphocyte infiltration and keratinocyte apoptosis. Part 2 focuses on patient management and therapeutic approaches and includes discussion on malignant transformation of oral LP.

Number V Oral lichen planus: clinical features and management

Oral lichen planus (OLP) is a relatively common chronic inflammatory disorder affecting stratified squamous epithelia. Whereas in the majority of instances, cutaneous lesions of lichen planus (LP) are self-limiting and cause itching, oral lesions in OLP are chronic, rarely undergo spontaneous remission, are potentially premalignant and are often a source of morbidity. Current data suggest that OLP is a T cell-mediated autoimmune disease in which auto-cytotoxic CD8+ T cells trigger apoptosis of oral epithelial cells. The characteristic clinical aspects of OLP may be sufficient to make a correct diagnosis if there are classic skin lesions present. An oral biopsy with histopathologic study is recommended to confirm the clinical diagnosis and mainly to exclude dysplasia and malignancy. The most commonly employed and useful agents for the treatment of lichen planus (LP) are topical corticosteroids but other newer agents are available.

A systematic review of placebo-controlled randomized clinical trials of treatments used in oral lichen planus

BACKGROUND

Oral lichen planus (OLP) is one of the commoner conditions seen in oral medicine clinics. Current treatments are palliative rather than curative. Numerous treatments have been tried but many have not been evaluated in randomized controlled trials (RCTs).

OBJECTIVES

To review the effectiveness and safety of any therapy compared with placebo for the treatment of symptomatic OLP.

METHODS

A systematic review of 11 RCTs, totalling 223 patients was done. The main outcome measures used were improvement of signs (erythema, reticulation, ulceration) and symptoms (pain, discomfort) usually after 8 weeks of therapy.

RESULTS

Eleven interventions were grouped into four therapeutic classes (topical ciclosporins, topical or systemic retinoids, topical steroids and phototherapy) for comparison. No therapy was replicated exactly. Trials recording the same outcomes in each therapeutic class were pooled. The largest number of pooled trials was four. Small odds ratios with very wide confidence intervals indicating statistically significant but imprecisely known treatment benefits were seen in all but one trial. Only systemic agents were associated with treatment toxicities; all other side-effects were mild and mainly local.

CONCLUSIONS

The results are tempered by the small study sizes, lack of replication, lack of standardized outcome measures and the very high likelihood of publication bias. Therefore this review provides only circumstantial evidence for the superiority of the assessed interventions over placebo for the palliation of symptomatic OLP. There is a need for larger placebo-controlled RCTs with carefully selected and standardized outcome measures.

[Mouth dryness and burning sensation of the oral mucosa: causes and possibilities for treatment]

Both sets of complaints, mouth dryness and a burning sensation of the oral mucosa, can have a variety of causes. Local and regional as well as systemic causes can be responsible for burning mouth syndrome. Diseases of the oral mucosa can have genetic, inflammatory, or neoplastic origins. Autoimmune diseases and allergies as well as different afflictions relating to internal medicine can be accompanied by a burning sensation in the oral mucosa. Neurological and psychiatric illnesses must be clarified during interdisciplinary diagnostics in order to identify idiopathic forms. The causes of mouth dryness are similarly complex. In addition to inadequate fluid intake, particularly in elderly patients, drug side effects or systemic diseases are frequently also responsible. Treatment is directed at the underlying disease; in ambiguous cases, symptomatic therapy can provide relief for medical complaints.

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.

The clinical manifestations and treatment of oral lichen planus

The progress in research on OLP and other autoimmune diseases has been significant. Coupled with a growing recognition of the clinical features and treatment options by dentists and physicians and fueled by the advances in immunosuppressive therapies, research will undoubtedly provide new insights into this complex disorder. It is likely that what is learned will enhance the understanding not only of OLP but also of many other mucocutaneous diseases.

Management of oral lichen planus

Lichen planus is a relatively common disorder of the stratified squamous epithelia. Most dental and medical practitioners see patients with lichen planus, but not all are recognized as having the disease. Patients with lichen planus may have concomitant involvement of the disease in multiple sites. Oral lichen planus lesions usually have a distinctive clinical morphology and characteristic distribution, but oral lichen planus may also present a confusing array of patterns and forms, and other disorders may clinically mimic oral lichen planus. The etiopathogenesis of lichen planus appears to be complex, with interactions between genetic, environmental, and lifestyle factors. Much has now been clarified about the etiopathogenic mechanisms involved and interesting new associations, such as with liver disease, have emerged. The management of lichen planus is still not totally satisfactory in all cases and there is as yet no definitive treatment that results in long term remission, but there have been advances in the control of the condition. Amongst the many treatments available, high potency topical corticosteroids remain the most reliably effective, though topical cyclosporine, topical tacrolimus, or systemic corticosteroids may be indicated in patients whose condition is unresponsive to topical corticosteroids.

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.

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.

Interventions for treating oral lichen planus

BACKGROUND

Oral lichen planus is a chronic autoimmune disease of unknown aetiology that affects the inner surface of the mouth. The symptomatic forms are painful,tend to worsen with age and with remissions being rare. Current treatment is palliative and not curative, many topical and systemic agents have been tried with little hard evidence for efficacy.

OBJECTIVES

To assess the effectiveness and safety of any form of palliative therapy against placebo for the treatment of symptomatic oral lichen planus.

SEARCH STRATEGY

Electronic databases, handsearching of conference proceedings and specific journals, researchers in the field, drug manufacturers.

SELECTION CRITERIA

Any placebo-controlled trial of palliative therapy for symptomatic oral lichen planus, using a randomised or quasi-randomised design that measured changes in symptoms and/or clinical signs.

DATA COLLECTION AND ANALYSIS

Change in symptoms (pain, discomfort) and clinical signs (visual impression, lesion measurements) at the end of therapy. Odds ratio of improvement vs no improvement for each trial outcome and pooling where appropriate.

MAIN RESULTS

A total of nine RCTs were identified. The nine interventions were grouped into four separate classes (cyclosporines, retinoids, steroids and phototherapy) for comparison. No therapy was replicated exactly, the closest replication involved two trials using high and low dose cyclosporine mouthwash. Only trials recording the same outcomes in each therapeutic class were pooled. The largest number of pooled trials was three. Large odds ratios with very wide confidence intervals indicating a statistically significant treatment benefit were seen in all trials. However this has to be tempered by considerations of the small study sizes, the lack of replication, the difficulty in measuring outcome changes and the very high likelihood of publication bias. Only systemic agents were associated with treatment toxicities, all other side-effects were mild and mainly limited to local mucosal reactions.

REVIEWER'S CONCLUSIONS

The review provides only weak evidence for the superiority of the assessed interventions over placebo for palliation of symptomatic OLP. The results highlight the need for larger placebo-controlled RCTs with more carefully selected and standardised outcome measures before between-treatment comparisons can be properly interpreted.

New and emerging therapies for lichenoid dermatoses

Lichenoid dermatoses comprise a significant proportion of dermatologic conditions. The pathophysiologic mechanisms are unclear for many such dermatoses making treatment difficult. Ongoing research into these mechanisms is allowing more directed intervention possible. This article describes some of the recent experiences in the therapy of lichen planus, lichen nitidus, toxic epidermal necrolysis, and graft versus host disease.

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.

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.

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.

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.

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: epidemiology, clinical characteristics, and associated diseases

Oral lichen planus (OLP) is a chronic inflammatory disease, the cause of which remains unknown. In the last few years, significant advances have been made in understanding the mechanisms involved in the pathogenesis of the disease. Data on HLA markers for OLP vary depending on the population studied. OLP is a disease primarily of adults (50 to 55 years of age) and predominantly affects women. Any site in the oral cavity may be involved, but the buccal mucosa and gingiva are the most common sites. OLP can have different clinical presentations, with the reticular, erosive, and atrophic types being the most commonly reported. OLP has been reported to be associated with different medical conditions such as diabetes, hepatitis C infection, liver disease, and oral cancer. With the exception of oral cancer, there are not good data to support such associations. The question that remains to be answered is why we see a higher prevalence of oral carcinoma in patients with OLP. The relative prevalence from our series was 1.2%. Therefore, we believe patients with OLP have a higher risk for oral cancer and should be monitored for malignant transformation once a year.

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.