What medicine is recommended for a smoker with melanoplakia?

Melanoplakia: No Specific Medical Treatment Available

There is no established pharmacological treatment for melanoplakia (oral mucosal melanosis). The primary management strategy is smoking cessation, as tobacco is the causative agent in most cases, and the pigmentation typically resolves spontaneously after cessation 1.

Understanding Melanoplakia in Smokers

What is Melanoplakia?

• Melanoplakia (smoker's melanosis) is a benign pigmentation of the oral mucosa caused by tobacco exposure, most commonly affecting the anterior mandibular gingiva and interdental papillae 1
• The condition represents increased melanin production in response to tobacco irritants, not a neoplastic process 1
• It typically appears after the third decade of life and progressively darkens with continued smoking 1

Critical Distinction from Malignancy

• Malignant melanoma must be ruled out when oral pigmentation appears in adulthood, particularly if lesions show concerning features 2, 1
• High-risk features requiring biopsy include: lesions on the palate or gingiva, increasing clear cells in epithelium, S-100 protein positive cells, and large numbers of melanophages in deep lamina propria 2
• Lesions on the lip (74% of cases) are generally benign, with mean diameter of 0.69 cm 2

Primary Management: Smoking Cessation

Recommended Cessation Pharmacotherapy

The National Comprehensive Cancer Network recommends combination nicotine replacement therapy (NRT) or varenicline as first-line smoking cessation treatment 3:

• Combination NRT: Nicotine patch (long-acting) PLUS short-acting formulation (gum, lozenge, inhaler, or nasal spray for breakthrough cravings) 3
• Varenicline: 12-week initial course, typical dosing per FDA label 3
• Bupropion: Alternative option at 150 mg twice daily after titration 4

Treatment Approach

• Pharmacotherapy must always be paired with behavioral counseling for optimal success 3
• Follow-up assessment should occur within 2-3 weeks of initiating therapy, then at no more than 12-week intervals 3
• Nicotine withdrawal symptoms peak within 1-2 weeks before subsiding 3

Expected Outcomes After Cessation

• Melanoplakia typically resolves spontaneously after smoking cessation, though the timeline for resolution varies by individual 1
• No topical or systemic medications accelerate pigment resolution 1
• Continued smoking perpetuates and worsens the pigmentation 1

Clinical Monitoring Requirements

When to Biopsy

Biopsy is mandatory if 2:

• Lesions occur on palate or gingiva (higher malignant potential)
• Progressive enlargement despite smoking cessation
• Irregular borders or color variation
• Ulceration or bleeding

Surveillance Strategy

• Document lesion size, location, and characteristics at baseline 2
• Re-examine at 3-month intervals during active smoking cessation 3
• Persistent or enlarging lesions after 6 months of confirmed cessation warrant biopsy 2

Important Caveats

Why No Pharmacological Treatment Exists

• Melanoplakia is a reactive process, not a disease requiring medication 1
• The pigmentation represents normal melanocyte response to chronic irritation 1
• Removing the causative agent (tobacco) allows natural resolution 1

Smoking and Melanoma Risk

• Smoking is an independent poor prognostic factor in cutaneous melanoma, with hazard ratio of 1.81 for melanoma-specific death in persistent smokers compared to never smokers 5
• Smoking renders men significantly more susceptible to developing melanoma metastases 6
• This underscores the critical importance of smoking cessation in any patient with pigmented oral lesions 5