What is the treatment for oral lichen planus?

Treatment of Oral Lichen Planus

The first-line treatment for oral lichen planus (OLP) is high-potency topical corticosteroids such as clobetasol 0.05% or fluocinonide 0.05%, with gel formulations preferred for mucosal disease. 1

First-Line Therapy

• Topical corticosteroids are the mainstay of treatment for symptomatic OLP, providing relief from discomfort and improving quality of life 2
• High-potency topical steroids (clobetasol 0.05% or fluocinonide 0.05%) should be applied directly to affected areas, with gel formulations specifically recommended for oral mucosal disease 1
• Treatment should continue until symptoms improve to Grade 1, followed by a tapering schedule over 3 weeks 1
• Common side effects of topical corticosteroids include secondary candidiasis, bad taste, nausea, dry mouth, sore throat, or swollen mouth 2

Second-Line Therapy Options

• Tacrolimus 0.1% ointment is recommended as an alternative first-line treatment for all grades of OLP 1
• For moderate to severe OLP that doesn't respond to topical treatments, consider:
  • Oral antihistamines for symptomatic relief of pruritus 1
  • Systemic corticosteroids (prednisone) for more severe cases 1, 2
  • Narrow-band UVB phototherapy if available 1

Refractory Cases

• For cases unresponsive to first and second-line treatments, consider:
  • Retinoids (if no childbearing potential) 1, 2
  • Doxycycline in combination with nicotinamide 1
  • Other steroid-sparing immunosuppressants such as:
    • Azathioprine 1
    • Cyclosporine 1, 2
    • Hydroxychloroquine 1
    • Methotrexate 1
    • Mycophenolate mofetil 1
  • Photodynamic therapy, which has emerged as a promising physiological treatment option 3

Special Considerations

• Biopsy is mandatory before initiating treatment to confirm diagnosis and rule out malignancy, particularly squamous cell carcinoma 4
• OLP is a chronic condition requiring long-term management and regular follow-up 2
• Erosive forms of OLP carry a risk of malignant transformation and require more aggressive treatment and monitoring 3, 5
• Treatment should address any potential triggers, including:
  • Immune dysregulation factors 4
  • Potential infectious triggers 4
  • Trauma and injury to oral tissues 4

Emerging Therapies

• JAK enzyme inhibitors are being investigated as novel pharmacological treatments 3
• Biologics (alefacept, efalizumab, basiliximab, TNF-α inhibitors like infliximab, rituximab) may be alternative approaches for refractory cases 2
• Extracorporeal photochemotherapy shows promise for difficult cases 2

Management Algorithm

1. Confirm diagnosis with biopsy to rule out malignancy 4
2. Assess severity of symptoms and clinical presentation
3. For mild to moderate symptoms: Start with high-potency topical corticosteroids (clobetasol 0.05% gel) or tacrolimus 0.1% ointment 1
4. For moderate to severe symptoms: Add oral antihistamines and consider short-course systemic corticosteroids 1
5. For refractory cases: Consider steroid-sparing agents or alternative therapies 1, 2
6. Schedule regular follow-ups to monitor response and assess for malignant transformation 4, 5