When should topical steroids be used in the mouth?

Topical Steroid Use in the Mouth: Indications and Guidelines

Topical corticosteroids should be used in the mouth for conditions with oral inflammation such as Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), eosinophilic esophagitis, lichen planus, and other inflammatory oral mucosal conditions, with application methods and potency tailored to the specific condition. 1, 2

Indications for Oral Topical Steroids

• Topical corticosteroids are effective in reducing oral inflammation in various blistering and inflammatory conditions affecting the mouth 1
• Specific conditions where topical steroids are indicated include:
  • Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) 1
  • Eosinophilic esophagitis 1
  • Oral lichen planus and lichenoid diseases 2, 3
  • Immune checkpoint inhibitor-related oral mucosal toxicities 2

Specific Formulations and Application Methods

• For SJS/TEN:

  • Consider using betamethasone sodium phosphate 0.5 mg in 10 mL water as a 3-minute rinse-and-spit preparation four times daily 1
  • For more potent treatment, clobetasol propionate 0.05% mixed in equal amounts with Orabase can be applied directly to the sulci, labial or buccal mucosae daily during the acute phase 1, 2

• For eosinophilic esophagitis:

  • Fluticasone propionate at doses of 440-880 μg per day for children and 880-1760 μg per day for adolescents/adults 1
  • Alternatively, viscous budesonide (500 μg) mixed in a sucralose suspension twice daily 1
  • Administration method: spray the metered dose inhaler in the mouth with lips sealed around the device, then swallow without rinsing 1
  • Patients should not eat or drink for at least 30 minutes after administration 1

• For oral lichen planus and lichenoid diseases:

  • High-potency topical steroids like clobetasol 0.05% gel are recommended 2, 3
  • Apply to affected mucosal areas once daily until symptoms improve to Grade 1, then taper over 3 weeks 2

Duration of Treatment and Tapering

• For ultra-high potency corticosteroids (clobetasol):

  • Limit use to 2-4 weeks to avoid adverse effects 2, 4
  • Consider tapering: once daily application for up to 2 weeks, then alternate days, and eventually twice weekly 2

• For high or medium-potency corticosteroids:

  • Can be used for up to 12 weeks 4
  • No specific time limit for low-potency topical corticosteroid use 4

Potential Adverse Effects and Monitoring

• Local adverse effects to monitor:

  • Oral candidiasis (fungal infection) is the most common side effect 1, 5
  • Take oral and lip swabs regularly if bacterial or candidal secondary infection is suspected 1
  • Treat candidal infection with nystatin oral suspension 100,000 units four times daily for 1 week, or miconazole oral gel 1

• Systemic absorption concerns:

  • Risk increases with higher potency, larger areas of application, and prolonged use 6
  • Children may absorb proportionally larger amounts and be more susceptible to systemic toxicity 6
  • Consider monitoring for hypothalamic-pituitary-adrenal (HPA) axis suppression with prolonged use 6

Supportive Measures During Topical Steroid Use

• Apply white soft paraffin ointment to the lips every 2 hours during acute illness 1
• Protect ulcerated mucosal surfaces with a mucoprotectant mouthwash three times daily 1
• Clean the mouth daily with warm saline mouthwashes or an oral sponge 1
• Use antiseptic oral rinses twice daily to reduce bacterial colonization (e.g., 1.5% hydrogen peroxide mouthwash or 0.2% chlorhexidine digluconate mouthwash) 1

Common Pitfalls and Caveats

• Avoid prolonged use of high-potency topical steroids to prevent local and systemic adverse effects 2, 6
• Be vigilant for fungal infections, which are a common complication of topical steroid use in the mouth 1, 5
• Consider the risk-benefit ratio carefully in children, pregnant women, and nursing mothers due to potential systemic absorption 6
• For conditions like eosinophilic esophagitis, be aware that symptoms typically recur when topical steroid therapy is discontinued 1
• When treating oral lichen planus, topical corticosteroids may decrease dry mouth symptoms that often accompany the condition 3