Treatment of Oral Lichen Planus
Apply clobetasol 0.05% gel or fluocinonide 0.05% gel to dried oral mucosa twice daily for 2-3 months, then taper gradually over 3 weeks. 1, 2
First-Line Topical Corticosteroid Protocol
Gel formulations are mandatory for oral mucosal disease—never use cream or ointment formulations intraorally, as they lack appropriate adherence and efficacy for oral lesions. 1, 2
Standard Treatment Regimen:
- Apply clobetasol 0.05% gel or fluocinonide 0.05% gel twice daily to completely dried oral mucosa for optimal medication adherence. 1, 2
- Continue treatment for 2-3 months until symptoms improve to Grade 1 severity. 1, 2, 3
- Taper gradually over 3 weeks after achieving Grade 1 improvement—abrupt discontinuation causes rebound flares. 1, 2, 3
- For localized lesions only, an alternative is clobetasol 0.05% ointment mixed in 50% Orabase applied twice weekly to dried mucosa. 1, 2
Alternative First-Line Agent:
- Tacrolimus 0.1% ointment is equally effective when corticosteroids are contraindicated or fail, applied twice daily. 1, 2, 4
- A split-mouth trial showed tacrolimus 0.1% and triamcinolone 0.1% paste had equivalent efficacy in reducing mucosal involvement and pain scores over 2 weeks. 1
Treatment Algorithm Based on Disease Severity
Mild to Moderate Disease:
- Start with high-potency topical corticosteroid gel (clobetasol 0.05% or fluocinonide 0.05%) twice daily for 2-3 months as outlined above. 2, 3
- Add oral antihistamines for additional symptom control if needed. 1, 2
Moderate to Severe Disease:
- Continue topical corticosteroids and add oral antihistamines. 1, 2
- Consider oral prednisone 15-30 mg for 3-5 days for acute severe flares. 2, 3
- Add narrow-band UVB phototherapy if available for widespread involvement. 1, 2
Severe or Refractory Disease:
- Escalate to systemic corticosteroids (oral prednisone or IV methylprednisolone) for severe cases. 1, 4, 5
- Consider steroid-sparing immunosuppressants: azathioprine, cyclosporine, hydroxychloroquine, methotrexate, or mycophenolate mofetil. 1
- Acitretin (if no childbearing potential) or doxycycline combined with nicotinamide are additional options. 1
- Refer to dermatology for systemic therapy management. 4, 5
Adjunctive Symptomatic Measures
- Compound benzocaine gel applied topically for severe pain control. 2, 3
- 0.1% chlorhexidine gargling solution to reduce inflammation and prevent secondary infection. 2, 3
- Barrier preparations such as Gengigel mouth rinse/gel or Gelclair for pain control. 1
- Advise patients to avoid irritants, strong soaps, fragranced products, and local irritants that exacerbate the condition. 3, 6
Critical Pitfalls to Avoid
- Never use cream or ointment formulations for oral disease—only gel formulations provide appropriate adherence for intraoral lesions. 1, 2, 3
- Never stop corticosteroids abruptly—always taper gradually over 3 weeks to prevent rebound flares. 1, 2, 3
- Wash hands thoroughly after application to avoid spreading medication to sensitive areas like eyes and to prevent partner exposure. 1, 3
- Monitor for candidiasis, which commonly occurs during topical steroid therapy and requires concurrent antifungal treatment. 7
- Watch for other side effects: cutaneous atrophy, adrenal suppression, hypopigmentation, contact sensitivity (burning, itching, dryness), bad taste, nausea, dry mouth, sore throat. 1, 3, 7
Follow-Up Protocol
- Schedule follow-up at 3 months to assess treatment response, ensure proper medication use, and monitor for adverse effects. 3, 6
- Most patients require 30-60 grams of clobetasol annually for maintenance after initial control is achieved. 1, 6
- Monitor for malignant transformation—instruct patients to report any persistent ulceration or new growth, as oral lichen planus carries a small risk of progression to squamous cell carcinoma. 3
- Long-term maintenance is typically required, as oral lichen planus is a chronic disorder that may persist for years and is more resistant to treatment than cutaneous forms. 4, 8, 5