A sore and sensitive tongue

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Photo Rounds

A sore and sensitive tongue

J Fam Pract. 2005 January;54(1):33-36

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References

1. Eisen D. The clinical features, malignant potential, and systemic associations of oral lichen planus: A study of 723 patients. J Am Acad Dermatol 2002;46:207-214.

2. Gorsky M, Raviv M, Moskona D, Laufer M, Bodner L. Clinical characteristics and treatment of patients with oral lichen planus in Israel. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:644-649.

3. Allen CM, Blozis GG. Oral mucosal lesions. In Cummings CW, Schuller DE (eds): Otolaryngology: Head and Neck Surgery, vol 2, 2nd ed. St Louis, Mo: Mosby-Yearbook; 1993;1374-1375.

4. Eisen D. The evaluation of cutaneous, genital, scalp, nail, esophageal, and ocular involvement in patients with oral lichen planus. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88:431-436.

5. Brown RS, Bottomley WK, Puente E, Lavigne GL. A retrospective evaluation of 193 patients with oral lichen planus. J Oral Pathol Med 1993;22:69-72.

6. Thorn JJ, Holmstrup P, Rindum J, Pindborg JJ. Course of various clinical forms of oral lichen planus. A retrospective follow-up study of 611 patients. J Oral Pathol 1998;17:213-218.

7. Porter SR, Kirby A, Olsen I, Barrett W. Immunologic aspects of dermal and oral lichen planus. A review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83:358-366.

8. Rozycki TW, Rogers RS, Pittelkow MR, et al. Topical tacrolimus in the treatment of symptomatic oral lichen planus: A series of 13 patients. J Am Acad Dermatol 2002;46:27-34.

9. Kaliakatsou F, Hodgson TA, Lewsey JD, Hegarty AM, Murphy AG, Porter SR. Management of recalcitrant ulcer-ative oral lichen planus with topical tacrolimus. J Am Acad Dermatol 2002;46:35-41.

10. Olivier V, Lacour JP, Mousnier A, Garraffo R, Monteil RA, Ortonne JP. Treatment of chronic erosive oral lichen planus with low concentrations of topical tacrolimus. An open prospective study. Arch Dermatol 2002;138:1335-1338.

11. Hodgson TA, Sahni N, Kaliakatsou F, Buchanan JA, Porter SR. Long-term efficacy and safety of topical tacrolimus in the management of ulcerative/erosive oral lichen planus. Eur J Dermatol 2003;13:466-470.

12. Shen JT, Pedvis-Leftick A. Mucosal staining after using topical tacrolimus to treat erosive oral lichen planus. J Am Acad Dermatol 2004;50-326.

13. Trehan M, Taylor CR. Low-dose excimer 308-nm laser for the treatment of oral lichen planus. Arch Dermatol 2004;140:415-420.

Management: steroids, immunosuppressants, surgery

Because fewer than 20% of patients experience total remission,⁵ treatment of OLP is chronic and palliative. Most symptomatic patients are taught to avoid exacerbating factors and given topical steroid therapy (dexamethasone rinse, fluocinolone gel, triamcinolone cream). Observation, intralesional and systemic corticosteroids, immunosuppressants, antifungals, retinoids, antimalarials, dapsone, oral psoralen-ultraviolet-light (PUVA) treatment, and surgical techniques (CO₂ and neodymium: yttrium-aluminum-garnet [Nd:YAG] laser therapy, cryotherapy, and excision) are also employed, alone and in combination.^5,8

Tacrolimus (Protopic), an immunomodulator, administered topically in 0.03% to 0.3% concentrations using Aquaphor or paraffin ointment base, has been shown effective and well tolerated in controlling symptoms,^8,9 and is a less costly alternative to topical cyclosporine.⁹ It has been demonstrated effective prospective-ly,¹⁰ and is safe in long-term therapy¹¹ of erosive OLP, but it has been reported in one case to cause hyperpigmentation of oral mucosa.¹²

A recent study¹³ demonstrated the utility of low-dose 308-nm excimer laser radiation for symptomatic OLP.

Patient management

Our patient was instructed to avoid foods and substances that caused irritation of her tongue and oral mucosa. In addition, she was prescribed topical fluocinolone gel 0.025% 3 times daily, and was given information about alternative treatment options, including tacrolimus and surgical therapy. She was instructed to perform gentle yet thorough daily oral hygiene and to follow-up in 6 months for re-examination.

Corresponding author
Amor Khachemoune, MD, CWS, Wellman Center for Photomedicine Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, 40 Blossom Street (BAR 314), Boston, MA 02114. E-mail: amorkh@pol.net.

CORRECTION

December 2004’s Photo Rounds, “Rupturing bullae not respondign to antiobiotics,” left out the names of two of the article’s authors. The correct authors of the piece are John Sauret, MD, FAAFP, Sandra Yale, DO, and Ahunna Ahiarah, MD. We regret the error.

A sore and sensitive tongue

References

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