From the Guidelines
To manage oral ulcers caused by Keytruda (pembrolizumab), start with good oral hygiene and use salt water or baking soda rinses 4-6 times daily to reduce inflammation and prevent infection, as recommended by expert opinion 1. For pain relief, use topical anesthetics like viscous lidocaine 2% or benzocaine products before meals. Over-the-counter pain medications such as acetaminophen or ibuprofen can help with discomfort. Apply topical corticosteroids like triamcinolone dental paste 0.1% to ulcers 2-3 times daily to reduce inflammation. For severe cases, your oncologist may prescribe oral corticosteroids like prednisone or temporarily pause Keytruda treatment. Avoid spicy, acidic, rough, or very hot foods that can irritate ulcers, and choose soft, bland foods instead. Stay well-hydrated and maintain nutrition despite discomfort. These ulcers occur because pembrolizumab, while activating the immune system against cancer, can sometimes trigger immune-related inflammatory reactions in the mucous membranes. Report persistent or severe ulcers to your oncologist promptly, as they may indicate a more serious immune-related adverse event requiring specialized management. Some key points to consider in managing oral ulcers include:
- Maintaining good oral hygiene to prevent infection
- Using topical treatments for pain and inflammation
- Avoiding irritants that can exacerbate ulcers
- Staying hydrated and maintaining nutrition
- Monitoring for signs of more serious immune-related adverse events. It's also important to note that the management of oral ulcers may involve a multidisciplinary approach, including input from oncologists, dentists, and other healthcare professionals, as suggested by recent expert consensus guidelines 1. However, the most recent and highest quality study on this topic is from 2015, which provides recommendations for the management of oral and gastrointestinal mucosal injury, including the use of oral care protocols and topical corticosteroids 1. Therefore, the most recommended approach is to follow the guidelines outlined in the 2015 study 1, which prioritizes good oral hygiene, topical treatments, and avoidance of irritants.
From the Research
Management of Oral Ulcers Caused by Keytruda (Pembrolizumab)
- Oral ulcers are a common side effect of Keytruda (pembrolizumab) therapy, which can be painful and affect a patient's quality of life 2, 3.
- The clinical presentation of oral ulcers caused by Keytruda can include lichenoid lesions, erythema multiforme, and acute graft-versus-host disease reactivation, with or without ulcerations 2.
- Management of oral ulcers caused by Keytruda typically involves topical and systemic steroids, which can lead to complete symptomatic response in most patients 2.
- In some cases, the severity of oral ulcers may necessitate temporary or permanent discontinuation of Keytruda therapy 2.
- Other treatments, such as photobiomodulation (low-level laser) therapy, may also be effective in managing oral ulcers caused by Keytruda 3.
Prevention and Treatment of Oral Ulcers
- Avoiding hard, acidic, and salty foods, as well as toothpastes containing sodium lauryl sulfate, may help prevent oral ulcers 4.
- Topical antiseptic/anti-inflammatory agents, such as triclosan and diclofenac, and local anesthetics, such as lidocaine, may be effective in treating oral ulcers 4.
- Mucoadhesive buccal films containing ornidazole and dexamethasone may also be a promising treatment for oral ulcers 5.
- Corticosteroids, such as prednisolone, may be used to treat severe cases of oral ulcers, but their efficacy is debated 4.
Diagnosis of Oral Ulcers
- The diagnosis of oral ulcers involves clinical evaluation, including the presence of vesicles or bullae, constitutional signs and symptoms, and lesions on the skin and/or other mucosa 6.
- In some cases, diagnosis may depend on culture or biopsy, particularly with the application of immunofluorescence to the surgical specimen 6.