Oral Lichen Planus: Management

Oral Lichen Planus (OLP) is considered to be a premalignant disorder(Incidence: 0.2% per year).

Treatment should be dictated by the severity of symptoms rather than clinical appearance.

Patients with asymptomatic OLP do not require treatment.
In symptomatic cases the mainstay of therapy is high-potency topical corticosteroids.
- Removal of cause: The causative factor is removed and this may lead to resolution of lesion subsequently. This is particularly applicable to lichenoid drug eruption.
- Limited lesions can be treated with a topical gel, while more extensive or difficult-to-reach areas are most effectively treated with a rinse.
- Patients with desquamative gingivitis can benefit from custom fabricated trays to apply the medication.
- In refractory cases, topical tacrolimus can be applied in addition to corticosteroids.
- In cases where topical therapy is inadequate, a short course of systemic steroids can be effective for severe flares.
- Some cases of OLP may require long-term use of systemic steroid-sparing agents to maintain adequate disease control.

Steroids

In most patients with erosive and ulcerative lesion, steroids are commonly used. The rationale behind their use is the ability to modulate inflammation and immune response.

Topical Steroids

Ointment : Clobetasol propionate (very potent, more advocated), Triamcinolone acetonide (0.1%)(intermediate potency).
Dosage : 2-3 times a day during 3 weeks – followed by tapering during the next 3 weeks, until a maintenance dose of 2-3 times a week is reached.
Steroid mouth rinse : Lesions that are extensive or in difficult-to-reach areas are most effectively treated with a rinse with Beclomethasone dipropionate (1mg).
Steroid coating in soft custom tray : In case of some painful gingival lesions, topical steroids may be applied using soft custom trays by coating steroids on the undersurface of the tray. This tray anchors to the dental arch while covering the painful gingival lesion.

Intralesional injections

Methylprednisolone 40 mg/mL.
Triamcinolone acetonide 10 mg/mL.

Systemic steroids

Justified to control symptoms from recalcitrant lesions.
1mg/kg daily for 7 days, followed by a reduction of 10mg each subsequent day.
Maintenance dose with topical steroids may be commenced during the tapering of systematic steroids.
Combination of prednisolone and levamisole : A regime consisting of prednisolone and levamisole has also been tried successfully recently. This systemic regime calls for prednisolone 5 mg and levamisole 50 mg tablets for first three days of rest and this schedule to be followed for two to three more weeks.
Side effects : Patients are likely to experience transient suppression of the hypothalamic-pituitary-adrenal (HPA) axis and should not swallow but “swish and spit out”.

Calcineurin Inhibitors

Cyclosporine and Tacrolimus are considered as second line therapy.

Cyclosporine

It is less effective than clobetasol propionate (clobetasol more effective in inducing clinical improvement).
However, clobetasol gives less stable results with higher incidence of side effects (non-severe).
Cyclosporine is not significantly better than 0.1% triamcinolone paste.
It shows no adverse effects, only temporary burning sensation.
It can be used both, topically and systemically.
The lesion shows complete healing with no recurrence following 8 weeks of systemic cyclosporine 8 mg/kg/day.
Oral lesions can be treated using cyclosporine as a rinse and expectorant. It is used as 5 mL rinse, TID, for 8 weeks.

Tacrolimus (0.1%)

Tacrolimus have better initial therapeutic response as compared to Triamcinolone acetonide (0.1%).
Tacrolimus has been labelled with the USFDA’s Black Box Warning : “Possibility of increased risk of malignancy (squamous cell carcinoma and lymphoma) in patients using topical tacrolimus / pimecrolimus for cutaneous psoriasis. These agents should be used in limited circumstances and patients made aware of these concerns”.
Tacrolimus should only be used by experts when symptomatic OLP lesions are recalcitrant to topical steroids.

Antifungal Agent

It is given when candidiasis is superimposed on lichen planus.
When potent topical steroids are used, a fungal infection may emerge. Hence, parallel treatment with antifungal drugs may be necessary when the number of applications exceed once a day and antifungal treatment itself may result in significant improvement of symptoms and clinical features.
The prophylactic antifungal therapy usually consists of clotrimazole oral troches (lozenges) or mouth paint. Nystatin and ketoconazole can also be used.

Vitamin A (Retinoid) Analog

Retinoids are useful, usually in conjunction with topical corticosteroids as adjunctive therapy either topically or systemically. This is because of their anti-keratinizing and immunomodulating effects.
They are particularly effective against keratinized reticular and plaque variants.
Topical Vitamin A acid (Retinoic acid) (0.1%) cream is also useful in resolution of the lesions, but withdrawal of the medication leads to rapid recurrence to the lesion very often.
The side effects of retinoids include foci of erythema during and after the topical treatment. For systemic retinoids, it includes liver dysfunction, cheilitis and dryness of mucous membrane.

Lycopene

Oxidative stress has been implicated in the pathogenesis of lichen planus, and a lower level of lycopene has been reported in erosive and atrophic OLP patients.
Lycopene was very effective in the management of OLP as per study under reference, wherein a higher (84%) reduction in burning sensation was seen in patients taking lycopene (8 mg/day) than in the placebo group (67%). All 15 (100%) patients in the lycopene group showed 50% or more benefit and 11 (73.3%) patients showed 70-100% benefit, while this number was only 10 and 4 (26.7%), respectively, in the placebo group.
Ref: Saawarn N, Shashikanth MC, Saawarn S, Jirge V, Chaitanya NC, Pinakapani R. Lycopene in the management of oral lichen planus: a placebo-controlled study. Indian J Dent Res. 2011 Sep-Oct;22(5):639-43. doi: 10.4103/0970-9290.93448. PMID: 22406705.

Psychotherapy

Emotional status of the patient is important in the development of this disease. In some cases, the lesion may regress when the patient is made aware of psychogenic implication of the condition and the nature of emotional stress is understood.
When the lesions are asymptomatic and there is no source of emotional distress, it is often advisable to refrain from therapy as failure to eradicate the lesion by medication may trigger the patient into becoming fearful of cancer.

Ultraviolet Therapy

In this form of therapy, psoralens and high intensity long wave ultraviolet A (PUVA) light is used as a therapeutic agent. The lesion shows improvement during and immediately after the treatment.

Surgical Therapy

It is indicated when conventional methods fail in ulcerative lesion and small solitary lesions.
In some cases, cryosurgery and cauterization have also been tried.

Dapsone Therapy

It is postulated that this particular agent may help to control the lymphocyte mediated progress of lichen planus by modulating the release of inflammatory or chemotactic factor for mast cells or neutrophils.
It is used in severe form of erosive lesions.

Symptomatic Therapy

It can be provided by topical analgesic, topical anesthetic and antihistaminic rinse.

Points to Note

A typical prescription for Oral Lichen Planus (*This is based on personal clinical experience, and not recommended as a definitive treatment guide.)

Tab Betamethasone (1mg) as mouthwash BD / TDS x 15 days OR Oint. Triamcinolone acetonide (0.1%) for local application BD / TDS x 15 days.
Clotrimazole mouth paint for local application BD / TDS x 5days.
Topical analgesic/anesthetic gel BD / TDS x 15 days.
Cap. Multivitamin (Vit A) OD x 15 days OR Cap Lycopene (4-5 mg) OD x 15 days.
Oint. Tacrolimus (0.1%) for local application BD x 15 days (In cases that are not relieved using topical steroid therapy).

Adv.

Scaling and oral hygiene maintenance.
Lifestyle modification towards a stress-free environment.

References

Martin S. Greenberg, Michael Glick, Jonathan A. Ship - Burket's Oral Medicine, 11th Edition (2008).
Anil Govindrao Ghom, Savita Anil Ghom (Lodam) - Textbook of Oral Medicine - Jaypee Brothers Medical Publishers (P) Ltd (2014).
Jean M. Bruch, Nathaniel S. Treister - Clinical Oral Medicine and Pathology-Springer International Publishing (2017).

*This article is an excerpt from the above mentioned books and Medical Sutras does not make any ownership or affiliation claims.