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

Changes in the Oral-Health-Related Quality of Life of Thai patients with oral lichen planus after topical corticosteroid treatment: a 1-month longitudinal study

BACKGROUND

Oral lichen planus (OLP) is a chronic inflammatory disease of the oral cavity that affects many patients' daily living activities. Topical corticosteroids are the first-line drug for treating OLP. The Oral Impact on Daily Performances index (OIDP) is an Oral-Health-Related Quality of Life (OHRQoL) measure developed to assess the ultimate impacts. The aims of this study were to evaluate the clinical, pain and OHRQoL responses after treating OLP patients with topical corticosteroids for 1 month, and secondly to assess the relationships of changes in the clinical sign score, pain score, and OHRQoL.

METHODS

Seventy-two OLP patients were treated by topical corticosteroids based on their dentists' clinical judgments. Clinical and patient-based outcomes were assessed at baseline and follow-up visit. The clinical outcomes were evaluated by the highest and total Thongprasom sign score. Patient-based outcomes were evaluated by numeric rating scale (NRS) and OIDP. The self-rated overall changes in quality of life during the 1-month treatment period using the Patient Global Impression of Change (PGIC) were also recorded at the follow-up visit.

RESULTS

This study comprised 59 women and 13 men. All clinical and patient-based outcomes were significantly reduced after 1-month treatment with topical corticosteroids (P < 0.01). The most commonly affected activities were Emotional stability, followed by Eating and Cleaning the oral cavity. Forty-six percent reported the same or up to moderately improved, while 54% had a greatly improved quality of life as assessed by PGIC. There were no significant differences in the improvement of clinical and patient-based outcomes between these groups. There were significant relationships between the differences in the highest Thongprasom sign score and the differences in total Thongprasom sign score (r = 0.293; P < 0.05), and the differences in total OIDP percentage score and the difference in pain score (r = 0.427; P < 0.001). The differences in the total Thongprasom sign score also significantly related to the difference in the total OIDP percentage score (r = 0.335; P < 0.01).

CONCLUSIONS

Topical corticosteroids were significantly effective after 1-month treatment of OLP based on the clinical and patient-based outcomes. The OHRQoL improvement was significantly related to the reductions in pain and clinical severity.

TRIAL REGISTRATION

The trial was registered at the Thai Clinical Trials Registry (TCTR identifier: TCTR 20221110001).

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.

Evaluating the Efficacy of the Er,Cr:YSGG Fractional Laser Before Treatment With Triamcinolone NN Ointment in Oral Lichen Planus Lesions

Introduction: It has been demonstrated that laser technology can enhance topical drug absorption. This study aimed to determine the effects of Er,Cr:YSGG laser radiation before the application of topical corticosteroids in the healing of oral lichen planus. Methods: In this double-blind split-mouth clinical trial, 32 lesions were chosen from eight patients affected by oral lichen planus (OLP). The oral lesions were randomly categorized into two groups. The first group had topical treatment with triamcinolone NN ointment and the second group had laser radiation (Er,Cr:YSGG) for eight weeks before starting the ointment. For each lesion, the irritating level based on the VAS score, the lesion level based on the Thongprasom scale score, and the healing time were measured, and the collected data were analyzed by the Friedman test and the Wilcoxon’s statistical test. Results: The mean healing time based on the verbal analog scale (VAS) score was not significantly different between the two treatment groups (P>0.05). The mean healing time based on Thongprasom scale scores did not show any significant difference between the two treatment groups (P>0.05). Conclusion: The application of the Er,Cr:YSGG laser before treatment with triamcinolone NN ointment did not show any advantage for the average healing time compared to a medicine regimen with only triamcinolone NN ointment.

French guidelines for the management of oral lichen planus (excluding pharmacological therapy)

INTRODUCTION

Oral lichen is a chronic inflammatory disease for which diagnostic management and follow-up are heterogeneous given the absence of specific guidelines in France. Our objective was to develop French multidisciplinary guidelines for the management of oral lichen.

MATERIALS AND METHODS

Working groups from the Groupe d'Etude de la Muqueuse Buccale (GEMUB) formulated a list of research questions and the corresponding recommendations according to the "formal consensus" method for developing practice guidelines. These recommendations were submitted to a group of experts and the degree of agreement for each recommendation was assessed by a scoring group.

RESULTS

Twenty-two research questions, divided into 3 themes (nosological classification and initial assessment, induced oral lichenoid lesions, and follow-up) resulted in 22 recommendations. Initial biopsy for histology is recommended in the absence of reticulated lesions. Biopsy for direct immunofluorescence is recommended for ulcerated, erosive, bullous types and for diffuse erythematous gingivitis. Management should include a periodontal and dental check-up, and investigation for extra-oral lesions. Hepatitis C testing is recommended only if risk factors are present. Definitions, triggering factors and the management of "induced oral lichenoid lesions" were clarified. Oral lichen must be monitored by a practitioner familiar with the disease at least once a year, using objective tools.

CONCLUSION

This formalised consensus of multidisciplinary experts provides clinical practice guidelines on the management and monitoring of oral lichen.

Micronutrients Profile in Oral Lichen Planus: a Review Literature

Oral lichen planus (OLP) is a relatively common chronic inflammatory disease. The micronutrients are critical factors in health of oral mucous and proper function of immune system. There have not been any review articles for evaluating trace element levels before and after standard treatments of OLP. The purpose of this study is to provide complete review of the association of micronutrients with OLP. Databases including PubMed, Google Scholar, Scopus, and Embase (Ovid) with keywords of oral lichen planus, OLP, oral disorder, micronutrients, trace element, nutrient element, antioxidant, oxidative stress, malnutrition, and essential trace elements, without time limitation (1900-2019) were searched to collect data on related articles. Total number of 58 original articles including 12 randomized clinical trials, 41 case-control, 4 case reports, and 1 cell line research were reviewed in this study. Lower levels of iron and its associated markers, such as hemoglobin and ferritin, increased levels of TIBC; reduced levels of zinc, calcium, vitamin D, vitamin B12, folic acid, and antioxidants such as vitamins C and E; and increased levels of oxidants and homocysteine, have been reported in OLP patients.

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.

Oral lichen planus: A disease or a spectrum of tissue reactions? Types, causes, diagnostic algorhythms, prognosis, management strategies

Oral lichen planus and lichenoid lesions comprise a group of disorders of the oral mucosa that likely represent a common reaction pattern to 1 or more unknown antigens. The coexistence of hyperkeratotic striation/reticulation, varying degrees of mucosal inflammation from mild erythema to severe widespread ulceration, and a band-like infiltrate of mononuclear inflammatory cells including activated T lymphocytes, macrophages, and dendritic cells, are considered suggestive of oral lichen planus and lichenoid lesions. Several classification systems of oral lichen planus and lichenoid lesions have been attempted, although none seem to be comprehensive. In this paper, we present a classification of oral lichen planus and lichenoid lesions that includes oral lichen planus, oral lichenoid contact lesions, oral lichenoid drug reactions, oral lichenoid lesions of graft vs. host disease, discoid lupus erythematosus, and systemic lupus erythematosus, lichen planus-like variant of paraneoplastic pemphigus/paraneoplastic autoimmune multiorgan syndrome, chronic ulcerative stomatitis, lichen planus pemphigoides, solitary fixed drug eruptions, and lichen sclerosus. We present the clinical and diagnostic aspects of oral lichen planus and lichenoid lesions, and discuss related treatment options.

Clinical Evaluation of CO2 Laser Vaporization Therapy for Oral Lichen Planus: A Single-Arm Intervention Study

Objective: The purpose of this study is to evaluate the efficacy of CO₂ laser vaporization therapy for oral lichen planus (OLP) refractory to conservative treatments. Methods: The study group comprised 16 patients with clinically and histologically diagnosed OLP. They underwent conservative treatment for 3 months using an adrenal cortex hormone ointment and azulene sulfonate sodium hydrate gargle. Patients who showed no improvement with conservative treatment underwent CO₂ laser vaporization therapy (3 W, continuous-wave mode). The assessment was performed using the numerical rating scale (NRS) as a subjective indicator and the Thongprasom sign score (TSS) as an objective indicator of OLP. These two scales were recorded during examinations performed before treatment and then at 7 days, 1, 3, and 6 months, and 1 year after irradiation. Differences between preirradiation and each point of time after irradiation were tested by Wilcoxon's signed-rank tests. Results: Laser irradiation was administered to 9 patients with 11 sites. The NRS score and TSS decreased at all 11 sites (100%) and 10 sites (90.9%) at 1 year after irradiation compared with preirradiation scores. The NRS score and TSS were statistically lower (p < 0.05) at 1 and 3 months (short-term) and 6 months and 1 year (mid-long-term) after irradiation than the preirradiation scores. There were no patients with malignant transformation during the study period. Conclusions: These single-arm clinical trial results show the efficacy of CO₂ laser vaporization therapy for OLP refractory to conservative treatment.

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.

The Pharmacologic Management of Common Lesions of the Oral Cavity

The oral ulcerations caused by aphtous lesions, herpetic lesions, candidiasis, ulcerative lichen planus, mucous membrane pemphigoid, and pemphigus vulgaris are managed in a step-up approach that can involve topical, intarlesional, and systemic pharmacologic management. This article reviews the common treatment agents, modalities, and dosages. The emphasis is on local pharmacologic therapies, yet systemic conditions that often present with such oral lesions are briefly reviewed, along with the appropriate management.

Medical Management of Oral Lichen Planus: A Systematic Review

INTRODUCTION

Oral Lichen Planus (OLP) is a chronic inflammatory, T-cell-mediated autoimmune oral mucosal disease with unclear aetiology. The clinical management of OLP poses considerable difficulties to the oral physician.

AIM

The aim was to assess the efficacy of any form of intervention used to medically manage OLP.

MATERIALS AND METHODS

We searched and analysed the following databases (from January 1990 to December 2014):- Cochrane Oral Health Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. All Randomised Controlled Trials (RCTs) for the medical management of OLP which compared active treatment with placebo or between active treatments were considered in this systematic review. Participants of any age, gender or race having symptomatic OLP (including mixed forms), unconnected to any identifiable cause (e.g. lichenoid drug reactions) and confirmed by histopathology have been included. Interventions of all types, including topical treatments or systemic drugs of variable dosage, duration & frequency of delivery have been considered. All the trials identified were appraised by five review authors and the data for all the trials were synthesised using specifically designed data extraction form. Binary data has been presented as risk ratios (RR) with 95% confidence intervals (CI) and continuous data as mean differences (MD) with 95% CIs.

RESULTS

A total of 35 RCTs were included in this systematic review on medical management of OLP. No strong evidence suggesting superiority of any specific intervention in reducing pain and clinical signs of OLP were shown by the RCTs included here.

CONCLUSION

Future RCTs on a larger scale, adopting standardized outcome assessing parameters should be considered.

Phototherapy approaches in treatment of oral lichen planus

Oral lichen planus (OLP) is a chronic immunologic mucocutaneous inflammatory disease of the oral mucosa. Since the etiopathology of OLP is idiopathic, treatment is usually symptomatic, therefore showing low predictability. Currently, topical corticosteroids are widely accepted as the standard therapy. However, for patients unresponsive to standard therapy for OLP, new treatment modalities have been sought. Phototherapy has recently been accepted as an alternative or adjunctive treatment modality for many conditions in medicine and dentistry. The aim of this study is to present the advantages and disadvantages of the different kinds of phototherapy used in treatment of OLP (UV phototherapy, lasers, and photodynamic therapy). The main outcome measures compared were improvement of signs and symptoms and OLP recurrence. Although some phototherapy techniques in the selected articles have demonstrated limited effects, there is no solid basis in evidence for the effectiveness of any of these treatments for OLP. Therefore, further research, especially randomized controlled clinical trials with long-term follow-up, is needed to give any solid recommendation on the use of phototherapy in the field of OLP treatment.

Interventions for erosive lichen planus affecting mucosal sites

BACKGROUND

Erosive lichen planus (ELP) affecting mucosal surfaces is a chronic autoimmune disease of unknown aetiology. It is often more painful and debilitating than the non-erosive types of lichen planus. Treatment is difficult and aimed at palliation rather than cure. Several topical and systemic agents have been used with varying results.

OBJECTIVES

To assess the effects of interventions in the treatment of erosive lichen planus affecting the oral, anogenital, and oesophageal regions.

SEARCH METHODS

We searched the following databases up to September 2009: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE (from 2005), EMBASE (from 2007), and LILACS (from 1982). We also searched reference lists of articles and online trials registries for ongoing trials.

SELECTION CRITERIA

We considered all randomised controlled trials (RCTs) that evaluated the effectiveness of any topical or systemic interventions for ELP affecting either the mouth, genital region, or both areas, in participants of any age, gender, or race.

DATA COLLECTION AND ANALYSIS

The primary outcome measures were as follows:(a) Pain reduction using a visual analogue scale rated by participants; (b) Physician Global Assessment; and (c) Participant global self-assessment.Changes in scores at the end of therapy compared with baseline were analysed.

MAIN RESULTS

A total of 15 RCTs were identified, giving a total of 473 participants with ELP. All studies involved oral ELP only. Six of the 15 studies included participants with non-erosive lichen planus. In these studies, only the erosive subgroup was included for intended subgroup analysis. We were unable to pool data from any of the nine studies with only ELP participants or any of the six studies with the ELP subgroup, due to small numbers and the heterogeneity of the interventions, design methods, and outcome variables between studies. One small study involving 50 participants found that 0.025% clobetasol propionate administered as liquid microspheres significantly reduced pain compared to ointment (Mean difference (MD) -18.30, 95% confidence interval (CI) -28.57 to -8.03), but outcome data was only available in 45 participants. However, in another study, a significant difference in pain was seen in the small subgroup of 11 ELP participants, favouring ciclosporin solution over 0.1% triamcinolone acetonide in orabase (MD -1.40, 95% CI -1.86 to -0.94). Aloe vera gel was 6 times more likely to result in at least a 50% improvement in pain symptoms compared to placebo in a study involving 45 ELP participants (Risk ratio (RR) 6.16, 95% CI 2.35 to 16.13). In a study involving 20 ELP participants, 1% pimecrolimus cream was 7 times more likely to result in a strong improvement as rated by the Physician Global Assessment when compared to vehicle cream (RR 7.00, 95% CI 1.04 to 46.95).There is no overwhelming evidence for the efficacy of a single treatment, including topical steroids, which are the widely accepted first-line therapy for ELP. Several side-effects were reported, but none were serious. With topical corticosteroids, the main side-effects were oral candidiasis and dyspepsia.

AUTHORS' CONCLUSIONS

This review suggests that there is only weak evidence for the effectiveness of any of the treatments for oral ELP, whilst no evidence was found for genital ELP. More RCTs on a larger scale are needed in the oral and genital ELP populations. We suggest that future studies should have standardised outcome variables that are clinically important to affected individuals. We recommend the measurement of a clinical severity score and a participant-rated symptom score using agreed and validated severity scoring tools. We also recommend the development of a validated combined severity scoring tool for both oral and genital populations.

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.

Oral lichen planus

Oral lichen planus (OLP) is a chronic, immune-mediated condition commonly affecting middle-aged women. The cause of OLP remains obscure. Strict clinical and histologic criteria need to be met to arrive at a definite diagnosis, thereby ruling out other conditions that may mimic OLP clinically and/or histologically. Although OLP is considered a premalignant condition, the risk for neoplastic change seems low.

Therapeutic Management of Oral Lichen Planus: A Review for the Clinicians

Lichen planus is a chronic, noninfectious, inflammatory disease of skin and mucous membrane. Intraorally the buccal mucosa, tongue and gingiva are the sites commonly involved. It affects women more often than men in a ratio 3:2. It has well-recognized clinical signs and symptoms, the symptoms may range from none, through mild discomfort to severe burning sensation. In comparison with cutaneous form, the oral lesions are more resistant to therapy and are less likely to undergo spontaneous remission.

Treatment is administered mainly to resolve symptoms and discomfort. Choice of treatment may vary from patient to patient depending on the severity of the lesion and systemic condition of the patient. A variety of agents have been employed to treat oral lichen planus, but corticosteroid remains the mainstay of treatment. However, in the recent past, newer drugs like Tacrolimus have shown promising results. In view of fact that there is a risk of malignant transformation of atrophic and erosive forms of oral lichen planus, the patients need to be actively treated and kept on long-term follow-up. This article highlights various agents used in treatment of oral lichen planus, their mechanism of action, dosage and untoward effects.

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.

Pathophysiology, etiologic factors, and clinical management of oral lichen planus, part I: facts and controversies

Lichen planus (LP) is an inflammatory disease of the stratified squamous epithelia of unknown etiology. LP affects most frequently the oral mucosa, but it may also involve other mucosa and the skin. Oral LP (OLP) most frequently affects woman aged between 30 and 60 years. Histopathologic examination typically shows orthokeratotic hyperkeratosis, basal cell degeneration, and a dense well-defined infiltrate of lymphocytes in the superficial dermis. OLP lesions may result from the induction of keratinocytes apoptosis by cytotoxic CD8+ T cells stimulated by a yet unidentified self-antigen on a genetically predisposed patient. The association of OLP with hepatitis C virus (HCV) has been more consistently demonstrated in the Mediterranean area. Although HCV RNA and HCV-specific CD4+ and CD8+ T cells have been retrieved in the mucosal lesions of patients with chronic HCV infection and OLP, the eventual pathophysiology of HCV in OLP lesions remains unclear. Available treatments of OLP are not curative, and many have potentially prominent side effects. The objectives of OLP management should be to prevent and screen for malignant transformation and alleviate symptoms on the long-term. Avoidance of potential precipitating drugs, tobacco, alcohol, and local trauma, as well as strict oral hygiene, is essential. The first-line pharmacologic treatment relies on topical steroids. Systemic steroids should be limited to the short-term cure of severe refractory OLP. Life-long clinical follow-up, at least annually, is fundamental.

Comparison of the Effect of Mouthwashes with and without Zinc and Fluocinolone on the Healing Process of Erosive Oral Lichen Planus

BACKGROUND AND AIMS

Lichen planus is a chronic inflammatory disorder with unspecified etiology, appearing as a result of stress, genetic predisposition and immunologic factors. Erosive type of the disease is more important because of its clinical symptoms of pain, irritation and malignancy risk. Despite various medications used, a definite cure for lichen planus is un-known. Regarding the effect of zinc on healing of ulcers, the aim of this study was to compare the effect of a mouthwash with and without zinc and fluocinolone on healing of erosive oral lichen planus.

MATERIALS AND METHODS

Twenty randomly-selected patients with erosive oral lichen planus were divided into two groups of 10. One group received zinc mouthwash with fluocinolone ointment and the other group received placebo with ointment. The largest dimension of the ulcers was measured by digital calipers and the intensity of pain was determined by visual ana-logue scale. Data was analyzed with Mann-Whitney U test.

RESULTS

Pain, irritation and lesion surface area decreased in both groups. Decrease in pain severity was identical in both groups (P = 0.11). However, decrease in surface area with zinc mouthwash plus fluocinolone was more than that with only fluocinolone (P = 0.037).

CONCLUSION

0.2% zinc mouthwash plus fluocinolone and only fluocinolone were both effective in decreasing pain, irrita-tion, and surface area of OLP. However, decrease in surface area with zinc mouthwash plus fluocinolone was more than that with fluocinolone alone.

Comparison of the effect of combination of triamcinolone acetonide and vitamin a mouthwash with triamcinolone mouthwash alone on oral lichen planus

BACKGROUND AND AIMS

Lichen planus is a relatively common mucocutaneous disease, with an unknown etiology. There is no complete cure for oral lichen planus (OLP), but some drugs, including corticosteroids, retinoids, cyclosporine and antibiotics are commonly used for treatment of OLP. The aim of the present study was to compare the effect of combi-nation of triamcinolone and vitamin A mouthwash with triamcinolone mouthwash alone on OLP.

MATERIALS AND METHODS

Twenty OLP patients were randomly divided into two groups of 10. The experimental group was treated with combination of triamcinolone and vitamin A mouthwash and the control group was treated with triamcinolone-containing mouthwash alone. The patients were examined once every two weeks and the lesion size, pain and burning sensation were recorded based on visual analogue scale during a two-month period. Data were analyzed by Mann-Whitney U test using SPSS software.

RESULTS

The use of combination of triamcinolone-vitamin A mouthwash was effective in decreasing the pain and burning sensation of OLP (P = 0.012). Decrease in pain and burning sensation were similar in both groups (P = 0.73). The use of combination of triamcinolone-vitamin A mouthwash led to a decrease in the size of keratotic, atrophic and erosive OLP lesions (P = 0). Decrease in the size of the lesions was significantly greater in the study group compared to the control group (P = 0.029).

CONCLUSION

The use of combination of triamcinolone-vitamin A mouthwash is effective in decreasing the size of keratotic, atrophic or erosive lesions.

Steriods in the treatment of lichen planus: a review

Steroids have been found to be effective in treating symptomatic oral lichen planus (OLP) by reducing pain and inflammation. In fact, systemic corticosteroids should be reserved for acute exacerbation, and multiple or widespread lesions. They may be indicated in patients whose condition is unresponsive to topical steroids. However, various potent topical steroids have been reported to be effective in the treatment of symptomatic OLP. They can be used as the first line drugs in the treatment of OLP with no serious side-effects. During the therapy, candidiasis was commonly found and in addition, bad taste, nausea, dry mouth, sore throat and swollen mouth may occur as minor side-effects from some topical steroids. Because OLP is a chronic disorder that requires long-term treatment, topical steroids are recommended for the treatment OLP because of minimal side-effects and the cost benefit. This manuscript reviews the use of steroids, especially its topical application, in the treatment of OLP.

The comparison of efficacy of adcortyl ointment and topical tacrolimus in treatment of erosive oral lichen planus

BACKGROUND AND AIMS

Oral lichen planus (OLP) is a common chronic mucocutaneous disease. Patients with atrophic and erosive lichen planus often have symptoms of soreness and need proper treatment. The main therapy of OLP has been the administration of topical or systemic corticosteroids. Potent topical corticosteroids have been increasingly prescribed in the treatment of erosive lichen planus. The purpose of this study was to compare the efficacy of adcortyl ointment (triamcinolone in orabase) with topical tacrolimus for the treatment of erosive oral lichen planus.

MATERIALS AND METHODS

Sixty Patients with histopathologically confirmed oral lichen planus were enrolled in the study. The severity of lesions was scored from 0 to 5 according to the criteria described in a previous study. Patients were randomly given adcortyl (group A) and topical tacrolimus ointment (group B) and asked to apply the medication on dried lesions 4 times a day. The lesions were evaluated after 4 weeks of treatment. Visual analogue scale was used to assess the severity of pain before and after treatment. The severity scores were analyzed using the Kruskal-Wallis k-sample test.

RESULTS

The average score of lesions improved from 3.4 to 1.5 in patients who received adcortyl ointment and from 3.2 to 1.2 in patients who received topical tacrolimus ointment. The differences between the im-provements in scores were not statistically significant in the two groups. The average pain severity in A and B groups was 8.2 and 7.8 at the beginning of treatment, and 3.5 and 3.2 at the end of treatment, respectively. There was a statistically significant reduction in pain severity in both groups.

CONCLUSION

Topical tacrolimus is a safe and effective alternative therapy in the treatment of oral lichen planus.

A scoring system for mucosal disease severity with special reference to oral lichen planus

BACKGROUND

To date, there is only weak evidence for the superiority of any interventions over placebo for the palliation of symptomatic oral lichen planus (LP). Further research involving large placebo-controlled, randomized clinical trials is needed. These will require carefully selected and standardized outcome measures.

OBJECTIVES

To formulate a scoring system for intraoral LP.

METHODS

One hundred and fifty-six patients with biopsy-confirmed LP were scored at the first and subsequent visits according to (i) extent of site involvement, (ii) disease activity at each site and (iii) an overall pain score as reported by the patient. Overall differences between clinical variants of LP were analysed using the Kruskal-Wallis test and pairwise differences by the Mann-Whitney U-test. Clinical sensitivity (Wilcoxon signed-rank test) was assessed by scoring patients before and after treatment (n = 23).

RESULTS

Reticular LP (n = 48) was the commonest single type of clinical presentation, followed by ulcerative (n = 30), atrophic (n = 22), desquamative (n = 18) and plaque (n = 1). The median severity and activity scores were 13/6 (reticular), 39/20 (ulcerative), 20/9 (atrophic) and 23/11 (desquamative). Two or more clinical variants were seen in 37 cases. Statistical significance was observed for differences between clinical variants (P < 0.0001) and variation in scores (P < 0.01) when ulcerative LP was compared with all other types. Clinical sensitivity was statistically significant (P < 0.01), while reproducibility was high and allowed the response to therapy to be easily assessed.

CONCLUSIONS

It is suggested that this scoring system is easy to use, reproducible and sensitive enough to detect clinical responses to therapy.

Oral mucosal disease: Lichen planus

Lichen planus (LP) is a common disorder in which auto-cytotoxic T lymphocytes trigger apoptosis of epithelial cells leading to chronic inflammation. Oral LP (OLP) can be a source of severe morbidity and has a small potential to be malignant. The diagnosis of OLP can be made from the clinical features if they are sufficiently characteristic, particularly if typical skin or other lesions are present, but biopsy is recommended to confirm the diagnosis and to exclude dysplasia and malignancy. OLP is treated with anti-inflammatory agents, mainly the topical corticosteroids, but newer agents and techniques are becoming available.

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.

Triamcinolone acetonide mouth rinses for treatment of erosive oral lichen planus: efficacy and risk of fungal over-infection

OBJECTIVES

To assess the efficacy of triamcinolone acetonide mouthrinse for treatment of erosive oral lichen planus (OLP), and to evaluate the risk of fungal over-infection.

PATIENTS AND METHODS

Clinical records of all cases of erosive and erosive-ulcerative OLP treated in our Oral Medicine Service over the period 1993-2003 were reviewed. All patients had been treated with mouthrinses containing triamcinolone acetonide at 0.3% (T1) or 0.5% (T2). Clinical outcome for each patient was classified at 1, 3 and 6 months after start of treatment as total remission (TR), partial remission (PR) or no remission (NR). Fungal over-infection was also recorded.

RESULTS

A total of 35 cases were included in the study. Clinical outcomes considering both treatment groups together (T1 + T2) were as follows: at month 1, 28.6% TR, 62.9% PR, 8.6% NR; at month 3, 57.1% TR, 37.1% PR, 5.7% NR; and at month 6, 80.0% TR, 17.1% PR, 2.9% NR. In four patients (11.4%) fungal over-infection was noted during the study period.

CONCLUSION

Triamcinolone acetonide mouthrinse is an appropriate treatment for erosive OLP, in view of the high efficacy and low risk of fungal over-infection.

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 randomized trial assessing the effectiveness of different concentrations of isotretinoin in the management of lichen planus

The aim of our 10-year study was to test the effectiveness of topical therapy based on 0.18% isotretinoin, comparing it with that most frequently used, i.e. at 0.05% concentration. Seventy patients with an established diagnosis of oral lichen planus were involved in the study. The patients were randomly divided into two groups, and the drug was administered topically at 0.05% and 0.18% concentrations. The drug at the higher concentration, according to the same protocol, was administered to the patients who did not benefit from the therapy at the lower concentration. None of the cases of reticular lichen planus showed clinical or histological improvement. In contrast, the atrophic-erosive forms showed a significant improvement, both clinical and histological: in 26 patients (at 0.18% concentration) and in nine patients (at 0.05% concentration), the symptoms, as well as the erosions or ulcers observed, disappeared. The disappearance of dysplasic phenomena was observed at 0.18% concentration. Topical application of the drug was accompanied by an increase in soreness and pain, as well as greater sensitivity to hot foods. However, these side effects were transitory, and considered acceptable by the patients. The proposed therapeutic protocol was effective towards highly active atrophic-erosive oral lichen planus with dysplasic phenomena, which is the form of the disease at higher risk of malignant evolution.

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.