Control Phase of Therapy

In the past, patients with DG were often told there was no known treatment for their condition and the patient would just have to learn to live with it. At this time, however, that kind of thinking is totally unacceptable and in most instances the patient’s disease or disorder can be markedly improved and on some occasions, clinical features are eliminated.48 In the foreseeable future, it may be possible to manage mucocutaneous diseases even more effectively with stem cell therapy.91 Meanwhile, current treatment modalities rarely fail to offer patient relief if not complete remission. Following successful diagnosis, the control phase is directed toward applying intense therapy to suppress the disease or disorder in a matter of days or weeks. The clinician must carefully balance the efficacy of treatment methods versus patient safety and patient acceptance. For example, if topical corticosteroids are prescribed the patient may become alarmed over the fact the material is identified as being for external use only. To avoid undue concerns, the patient should be informed that off label use of topical corticosteroids in the oral cavity is largely accepted and has been documented by many scientific papers as a suitable alternative to systemic corticosteroid therapy.17,30,57,64,75

Topical corticosteroids (Box 6) or other topical anti-inflammatory medicaments (Box 7) often require multiple daily applications so they should be of sufficient potency to avoid patient disenchantment if improvement is minimal.

Box 6. Topical and Intralesional Corticosteroids.
High Potency Topical Corticosterdroids
  • 0.25% Desoximetasone – spray, ointment or gel
  • 0.20% Fluocinolone – cream or ointment
  • 0.05% Fluocinonide – cream, ointment or gel
  • 0.50% Triamcinolone Acetonide – cream or ointment
  • Monitor quantity used and do not exceed 15 grams within two weeks

Very High Potency Topical Corticosteroids

  • Betamethasone dipropionate – 0.05% gel, cream, ointment
  • Clobetasol 0.05% – gel, cream, ointment
  • Halobetasol – 0.05% cream, ointment

Intralesional Corticosteroids

  • Triamcinolone acetonide – 5 ml vial containing 10 mg/m
  • Use 1 ml tuberculin syringe
  • Inject 0.1 mg per square cm of lesion
  • May repeat if necessary 2-3 times at 3-4 week interval
  • Do not use on gingiva or hard palate!
Box 7. Other Intraoral Treatments.
  • Topical tacrolimus (Protopic) – FDA warning
  • Topical pimecrolimus (Elidel) – FDA warning
  • Tacrolimus rinse – 1 mg/1000 ml. Rinse 4x daily
  • Effective plaque control
  • Topical cyclosporine A – expense
  • Soft “plumper” mouthguards – prevent cheek, lip and tongue irritation
  • Replace faulty restorations or restorations causing a contact lichenoid reaction

Patients should also be informed about possible adverse side effects of their proposed therapy so they may be prepared should side effects occur (Box 8). If they do develop side effects, they should be instructed to inform the clinician immediately. As mentioned, the most common side effect of the use of topical immunosuppressants is secondary candidiasis. The presence of this condition may cause the patient to believe they are not successfully responding to therapy since their mouth continues to be uncomfortable. These factors, disenchantment and adverse side effects can usually be avoided by discussions with the patient early in the treatment process; by evaluating the patient every 2-3 weeks; and changing treatment if results are minimal or adverse side effects occur.74,75

Box 8. Potential Adverse Effects of Topical or Intralesional Corticosteroids.

Potential Oral Adverse Effects:

  • Xerostomia
  • Candidiasis
  • Epithelial atrophy

Potential Systemic Adverse Effects:

  • Adrenal suppression
  • Hypertension
  • Blurred vision
  • Elevated blood glucose
  • GI hemorrhage

To date, no study has confirmed an adverse systemic reaction to judicious application of oral topical or intralesional cortcosteroids.