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CRITICAL REVIEWS IN ORAL BIOLOGY & MEDICINE |
Vesiculo-erosive Oral Mucosal Disease—Management with Topical Corticosteroids: (1) Fundamental Principles and Specific Agents Available
M.A. González-Moles1,* and
C. Scully2
1 Professor of Oral Medicine, Departamento de Medicina Oral, Facultad de Odontología, Universidad de Granada, Campus de Cartuja sn, 18071, Granada, Spain; and
2 Dean and Director of Studies and Research, Eastman Dental Institute for Oral Health Care Sciences, University College London, University of London, UK;
Correspondence: * corresponding author, magonzal{at}ugr.es
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ABSTRACT
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Vesiculo-erosive diseases of the oral mucosa pose a major challenge in oral medicine, because they are chronic, painful, and interfere with the daily activities and quality of life of the patients, including disturbing eating, drinking, talking, and personal relationships. Many are autoimmune diseases, and corticosteroid therapy is currently central to their treatment. These diseases present with inflammation and alterations to epithelial integrity, through cell and/or humoral immunity-mediated attack on epithelial-connective tissue targets. Until recently, despite their serious adverse effects, it was necessary to prescribe systemic corticosteroids to control severe erosive oral diseases. Now, however, many of these diseases can be controlled by high-potency topical corticosteroids, which have proved to be highly efficacious and to cause fewer adverse effects compared with systemic corticosteroids. Nevertheless, although topical corticosteroids are still the most widely used drugs in the practice of oral medicine, the scientific body of evidence for their use in the oral cavity is virtually non-existent, and therefore many of the protocols followed are, of necessity, drawn from experience of their use in a dermatological setting. This review aims to set out the key aspects of the use of topical corticosteroids in oral medicine. The issues covered include the indications and basic rules for their use, the types of corticosteroids, the drug selection, and the specific formulations.
Key Words: erosive lesions • oral mucosa • topical • corticosteroids
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(I) IMMUNOLOGICALLY MEDIATED DISEASES THAT AFFECT THE ORAL MUCOSA
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Immunologically mediated diseases that affect the oral mucosa present with inflammation and loss of epithelial integrity, through cellular and/or humoral immunity-mediated attack on epithelial-connective tissue targets. The main clinical features are ulceration and reddening, with pain that can be severe and debilitating. In many patients, these lesions are chronic and/or present a marked tendency to recur, and they often significantly interfere with such basic activities as eating, drinking, talking, and maintaining normal social relationships (González-Moles et al., 2002b, c). Furthermore, if these diseases affect the gingivae, the pain often prevents adequate oral hygiene, and this favors the appearance of gingivitis and halitosis. Increased gingival bleeding, reddening, and ulceration worsen the physical appearance, and this can increase the social isolation (González-Moles et al., 2003).
For all these reasons, vesiculo-erosive oral lesions of autoimmune etiology pose a major challenge in oral medicine.
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(II) CORTICOSTEROIDS
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Corticosteroids play a central role in the treatment of vesiculo-erosive lesions. However, the frequency and severity of the adverse effects associated with the use of systemic corticosteroids have led to the increased use of topical corticosteroids (TCs) (Scully et al., 1998). In contrast, evidence for the efficacy of TCs in oral medicine is limited, and many of the protocols followed are drawn from experience gained from their use in a dermatological setting (Regezi and Sciubba, 1999; Kalmar, 2000).
This review aims to set out the key aspects of TC use in oral medicine.
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(III) MODE OF ACTION OF CORTICOSTEROIDS
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The therapeutic efficacy of corticosteroids, which was initially described about half a century ago (Glaser et al., 1951), is now known to derive from their anti-inflammatory and immunosuppressant properties.
The anti-inflammatory action of glucocorticoids is based on a range of actions (Barnes, 1998) involving the glucocorticoid receptors, the glucocorticoid-responsive genes, the release of anti-inflammatory molecules such as lipocortin-1, interleukins IL-10, IL-1ra, and nuclear factor- B, by macrophages, eosinophils, lymphocytes, dendritic cells, neutrophils, and endothelial and epithelial cells. Lipocortin-1, a member of the annexin superfamily of proteins, is one of the ‘second messengers’ of the anti-inflammatory actions of glucocorticoids, acting through inhibition of prostaglandin formation as well as playing a major regulatory role in systems as diverse as cell-growth regulation and differentiation, neutrophil migration, CNS responses to cytokines, neuroendocrine secretion, and neurodegeneration. Glucocorticoids also induce the transcription of the gene encoding the inhibitor of Nuclear Factor Kappa B subtype a (IBa), which reduces the amount of NF-B that translocates to the nucleus and the secretion of pro-inflammatory cytokines (Scheinman et al., 1995). The immunosuppressant effects of corticosteroids derive mainly from the suppression of antigen-driven T-cell proliferation through the inhibition of interleukin-1 (IL-1) release from monocytes (Imagawa et al., 1995). At higher doses, they can also interfere with antibody formation (Streeten and Phil, 1975).
Corticosteroids can therefore: reduce the emigration of leukocytes and exudation of plasma constituents, thereby eliminating the edema; maintain the integrity of cell membranes, thus avoiding excessive swelling of cells; inhibit the release of lysozymes from granulocytes and phagocytosis; and stabilize the membranes of the intracellular lysosomes, thereby avoiding release of further hydrolytic enzymes, intracellular digestion, and spread of the inflammatory process (Streeten and Phil, 1975). Corticosteroids also inhibit fibroblast proliferation, suppressing fibrosis (Streeten and Phil, 1975).
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(IV) INDICATIONS FOR USE OF TCS IN ORAL MEDICINE
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The main oral mucosal conditions that are amenable to treatment with TCs are listed in Table 1 . Knowledge of the natural history of the disease, when this is predictable, is important for selection of the appropriate treatment, and the clinician should take into account the following options when considering the possible use of a TC:
- (A) A short course of TCs can accelerate remission without producing adverse effects in some ulcerative diseases which have a natural tendency to remit spontaneously, such as recurrent aphthous stomatitis (RAS), some cases of erythema multiforme (EM), and drug-induced ulceration. The paradigm of this type of disease is RAS, where patients suffer monthly outbreaks of aphthae that last from 3 to 10 days (Scully et al., 2003). In these patients, the early application of TCs can prevent the attack.
- (B) TCs must be used for longer, less predictable periods in diseases that tend to be chronic and/or show a marked tendency to recurrence, such as severe RAS (Scully et al., 2003), erosive oral lichen planus (OLP), specific forms of EM, and mucous membrane pemphigoid (MMP) (Scully et al., 1999; Chan et al., 2002). Consensual agreement was recently reached for the use of TCs in patients with ‘low-risk’ forms of MMP, in which the disease involves only the oral mucosa and/or the skin (Chan et al., 2002).
- (C) In very severe cases of ulceration, a maintenance regimen of TCs can be used after the disease has been controlled by a short course of systemic corticosteroids, and it can also be started simultaneously with the systemic therapy. This maintenance regimen can often prevent recurrence, while avoiding the adverse effects associated with a long course of systemic corticosteroids (Lozada-Nur et al., 1991).
- (D) In certain disease conditions, treatment with TCs alone is unlikely to suffice. Autoimmune diseases with multiple organ or site involvement and high levels of circulating antibodies, such as pemphigus vulgaris (Scully and Challacombe, 2002), or the 10–30% of pemphigoid patients with high levels of circulating antibodies, or erosive lichen planus affecting oral and extra-oral locations, among others (Laskaris and Angelopoulos, 1981; Nisengard and Neiders, 1981; Fine et al., 1984; Kelly and Wojnarowska, 1988; Manton and Scully, 1988; Chan et al., 1993; Domloge-Hultsch et al., 1994; Dayan et al., 1999), must almost inevitably be treated with systemic corticosteroids and/or other immunosuppressant therapies (Nisengard and Rogers, 1987). The presence of high levels of circulating antibodies in pemphigus typically indicates that other organs and mucosae (the skin and esophageal, genital, nasal, pharyngeal, laryngeal, and ocular mucosae) may be severely affected (Mignogna et al., 1997). The more severe forms of EM, such as the Stevens-Johnson syndrome and toxic epidermal necrolysis, must be treated from the outset with systemic corticosteroids in a hospital setting, because of the multiple system involvement. Likewise, the use of TCs is mandatory in patients with MMP who present with persistent oral lesions or the onset of ocular lesions (Ahmed et al., 1991; Scully et al., 1999).
However, although treatment with oral TCs would be clearly inadequate, it may be appropriate for as long as oral lesions alone are present or the patient has only low titers of circulating antibodies. However, in these cases, treatment with systemic corticosteroids may be necessary if the weekly follow-up or the monthly measurement of circulating antibodies indicates an imminent increase in the disease severity (Scully and Challacombe, 2002).
Finally, the medical history of the patient is another crucial factor in the selection of treatment. TCs can be used to relieve oral symptoms in patients with clear contraindications for systemic corticosteroids, such as those with untreated tuberculosis or a severe psychosis (Goldstein and Goldstein, 1996), and in patients who have suffered adverse effects from systemic steroids, such as osteoporosis in the lumbar spine, hypertension not controlled by anti-hypertensive therapy, acute steroid-induced psychosis, and herpes-virus-induced corneal ulceration.
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(V) PROTOCOLS FOR TC USE
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When a TC is prescribed, and especially when a prolonged course is predicted, the basic rule is that a TC of a potency appropriate to the severity of the clinical symptoms should be used, at the lowest possible concentration and frequency compatible with maintaining the effectiveness of the treatment, in a vehicle that minimizes the area exposed to the drug. It should always be taken into account that these drugs do not cure the disease but rather control or relieve the symptoms.
The specific diagnosis, the severity of the oral disease, the presence or absence of extra-oral lesions, and the medical history of the patient are the key factors that determine the selection of a topical or systemic treatment (Brown et al., 1993). Furthermore, these factors also influence the choice of drug, specific formulation, and treatment regimen (Vincent et al., 1990; Lozada-Nur and Miranda, 1997).
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(VI) TYPES OF TCS AND SELECTION OF DRUG
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Table 2 lists the main corticosteroids topically used in the USA, with their commercial names and concentrations, ordered according to their potency (Regezi and Sciubba, 1999). Although it is a modification of a previously published list of drugs used for skin diseases (Cornell and Stoughton, 1984), the Table gives an idea of the potency of the active principles for their application in the oral cavity (see below). Table 3 exhibits the most common formulations used for the application of the most widely known TCs.
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Table 2. Examples of Topical Corticosteroids Ranked According to Potency (from higher to lower; the products within each numbered group have similar potency)
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Table 3. Common Formulationsa Used for the Application of the Most Widely Used Topical Corticosteroids in Oral Medicine
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Factors that influence the effectiveness of TCs in oral medicine include: the intrinsic potency of the drug, which can be significantly increased by the halogenation of the steroid; esterification, which makes the drug more lipophilic and gives it greater penetrability; the contact time between the drug and lesion and the vehicle used to apply it; and an increased concentration, which can increase its clinical effectiveness, although no additional advantage is obtained beyond certain limits (Regezi and Sciubba, 1999).
Logically, the success of a topical medicine depends on the drug being in contact with the lesion for an appropriate time. Two main factors are involved. The first is the number of applications per day. When high-potency corticosteroids are used (see later), two or three daily applications are generally prescribed (Lozada, 1980; Lozada-Nur et al., 1991, 1994; Lozada-Nur and Miranda, 1997; González-Moles et al., 2002a,b,c, 2003). This daily frequency, however, although quite low, may enhance patient compliance (Lozada-Nur and Miranda, 1997; González-Moles et al., 2002b,c, 2003). When less-potent TCs are used, the number of daily applications needs to be considerably increased (from 5 to 10 daily) for real benefit to be obtained, and this can, in some cases, reduce patient compliance to unacceptably low levels (Lozada-Nur and Miranda, 1997).
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(VII) FORMULATION OF TCS
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A second factor that decisively affects the duration of the drug-lesion contact is the vehicle used for the specific TC formulation. Adherent vehicles and aqueous solutions are among the most widely used, but TCs have been applied in various vehicles. Vehicles used include orabase (Stoy, 1966), cylactin (Rodu and Russell, 1988), cyanoacrylate (Jasmin et al., 1993), bioadhesive patches made of cellulose derivatives (Mahdi et al., 1996), gels (Regezi and Sciubba, 1999), and denture adhesive paste (Lo Muzio et al., 2001).
Orabase is an adhesive paste widely used as a vehicle in TC therapy (González-Moles and Bagan-Sebastian, 2000; González-Moles et al., 2003). It consists of a combination of gelatine, peptin, and sodium carboxymethylcellulose in a plasticized hydrocarbon gel that is free of antibiotics, analgesics, and antiseptics (Lozada-Nur et al., 1994). Gels have the drawback of causing pain in some patients, secondary to irritation caused by the alcohol in their formulation (Regezi and Sciubba, 1999).
Some clinicians advocate the application of TCs in creams. However, although, from the authors’ personal experience, they can be acceptable to patients, there is little scientific evidence for their use, and they can be expensive. Ointments do not have adhesive properties and are rarely used alone in oral medicine (Regezi and Sciubba, 1999), although, when mixed in equal parts with adhesive pastes, they are widely used as a vehicle for topical corticosteroids (Lozada-Nur and Miranda, 1997).
Adhesive paste for dentures, which contains only inactive ingredients, was also recently introduced as an adherent vehicle (Lo Muzio et al., 2001) and has shown excellent bioadhesive properties, due to its high molecular weight (above 100,000), the flexibility of the polymeric chain, the greater number of carboxylic groups, and its ability to form bonds with hydrogen at pH 4 and 5 (Lozada-Nur and Silverman, 1980; Pimlott and Walker, 1983; Durrani et al., 1992; Bremecker et al., 1984; Yotsuyanagi et al., 1985; Nagai, 1986).
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(VIII) APPLICATION OF TCS
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Patients prescribed TC in an adherent vehicle should be instructed to apply a small amount to the target area after meals, and not to eat or drink for at least 30 min. It is best not to rub the TC in, because this can produce irritation (Lozada-Nur et al., 1991, 1994). The patient should apply the TC in front of a mirror, using a container that holds the amount required for a single application, thereby controlling the dose applied and increasing compliance (Lozada-Nur et al., 1994). One of the main shortcomings of adherent vehicles is that the clinician cannot precisely predict the time that the drug will be in contact with the lesion, because it will probably be displaced from its initial location due to oral movements and the moisture in the oral cavity. Losses of 85–90% of the total dose applied have been reported (Lozada-Nur et al., 1994). Additionally, in deep and extensive lesions of the oral mucosa, it can be difficult for patients to apply the paste to the entire surface of the lesion (González-Moles et al., 2002a,b,c). Preparations such as orabase will not adhere to wet surfaces, so the mucosa and lesion must be gently dried with gauze before application. Finally, patients poorly tolerate the granular texture of some adhesive preparations, such as orabase (Lozada-Nur et al., 1991). For small and accessible erosive lesions, or those located on the gingiva and palate, the lesions can be treated by the use of an adherent paste in a made-to-measure tray, which allows for accurate control over the contact time and ensures that the entire lesional surface is exposed to the drug (Lozada-Nur and Miranda, 1997; González-Moles and Bagan-Sebastian, 2000; González-Moles et al., 2002a,b,c, 2003). Creams or gels can be used in the same way or beneath a veneer (Wray and McCord, 1987).
The recent proposal (Lo Muzio et al., 2001) to use adhesive denture paste as the vehicle for TCs appears to avoid some of the above disadvantages. According to those authors, this adhesive paste demonstrates stability and bioadhesive properties for a period of 12 hrs after application, especially in localized lesions, together with a slow and sustained release of drug that yielded good clinical results. However, there are some concerns about a possible overdose from such a sustained release over long periods (González-Moles et al., 2002a).
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(IX) TC MOUTHRINSES
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The great majority of the drawbacks presented by adherent vehicles are avoided by the use of aqueous TC mouthrinses, when the clinician can be certain that the contact time is adequate and that the drug will be in contact with all lesions, however deep or extensive, for the prescribed time. Furthermore, the corticosteroid is reported to be released more readily to the oral mucosa when an aqueous solution is used (Ungphaiboon and Maitani, 2001).
The main disadvantage of mouthwashes is that the TC will be in contact with all of the mucosa, including unaffected areas, thereby increasing the surface area of absorption and the risk of adverse effects. These problems can be exacerbated by the presence of ulcerated surfaces and by the increased pressure exerted by the liquid on the mucosa as a result of the natural rinsing movements made by the patient. Furthermore, an aqueous preparation can be involuntarily ingested more easily than an adherent vehicle, which would also increase the amount of corticosteroid absorbed and the ensuing possible risk of adverse effects. Hence, patients must be clearly informed about the need to avoid ingesting the drug. Finally, the lesional exposure to the medication in a mouthwash is likely to be brief.
Despite the potential shortcomings of TCs in aqueous preparations, excellent outcomes have been achieved (González-Moles et al., 2002a,b,c). The mouthrinse is almost certainly the most widely indicated vehicle in oral medicine, although Thami and Bhalla (2003) proposed using the patients’ saliva as the vehicle for TCs, which they designated the ‘chew-and-spit method’. With this approach, the patient is directed to chew or suck a betamethasone (1 mg) tablet, mixing it in the mouth with his/her own saliva and keeping it there without swallowing for as long as possible, generally for 10 to 15 min. This method appears adequate, but has some disadvantages. First, it cannot be guaranteed that the tablet is completely dissolved, so that the final concentration of corticosteroid with which the patient is treated cannot be ensured. Moreover, this approach cannot be used in dry mouths, a frequent condition in some patients—for example, in those with altered emotional states commonly associated with oral lichen planus (González-Moles, 2003).
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(X) TYPES OF TCS USED IN ORAL MEDICINE
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TCs known to be used in oral medicine can be classified broadly as having mild, moderate, high, or very high potency. The vasoconstriction test (McKenzie and Stoughton, 1962) is used to assess the biological activity of a TC and is considered to predict its therapeutic efficacy (Cornell and Stoughton, 1985).
(X.1) Mild-potency Steroids
Although the most appropriate indications for mild-potency TCs have not been clearly defined in scientific studies, they are generally considered appropriate for the treatment of clinically unimportant autoimmune diseases of the oral mucosa, and for maintenance treatment in more severe diseases that have responded to systemic corticosteroids and/or high-potency TCs.
Mild-potency steroids such as hydrocortisone hemisuccinate find favor in some patients with minor aphthae, although patients typically require more potent steroids, such as clobetasol 17-propionate, fluocinonide, or triamcinolone acetonide (Temovate monograph, 1983; Cornell and Stoughton, 1985; Jacobson et al., 1986; Vickers, 1987; Lozada-Nur et al., 1991, 1994; Stoughton, 1992).
(X.2) Moderate-potency Steroids
There are very few published reports on the efficacy of triamcinolone acetonide, an even less potent TC than those mentioned above. In the opinion of some experienced authors (Lozada-Nur et al., 1991; Lozada-Nur and Miranda, 1997), its potency is unfortunately inadequate, with patients needing numerous daily applications to obtain any response. In contrast, others (Vincent et al., 1990) used 0.2% triamcinolone acetonide in aqueous solution and reported complete resolution of symptoms in 67% of their patients with oral lichen planus.
(X.3) High-potency Steroids
Clobetasol
Clobetasol 17-propionate is currently the most widely used potent topical corticosteroid. Chemically, it is 21-chloro-9-fluoro-11beta, 17hydroxy-16beta-methylpregna-1-4-diene-3, 20-dione, 17-propionate (Temovate monograph, 1983). The exceptional properties of clobetasol propionate have been demonstrated in healthy human volunteers and in animal models (Temovate monograph, 1983; Cornell and Stoughton, 1985; Stoughton, 1992). It induces vasoconstriction, followed by a reduction of the inflammation, presumably due to an alteration of histamine levels and to the effects of the catecholamines on peripheral blood vessels (Vickers, 1987; Lozada-Nur et al., 1991). Clobetasol has demonstrated superior therapeutic effects compared with other TCs (Temovate monograph, 1983; Cornell and Stoughton, 1985; Rodstrom et al., 1994; Carbone et al., 1999), since it allows the disease symptoms to be controlled with a restricted number of daily applications (Hersle et al., 1982; Carbone et al., 1999), and provides a better initial control of the symptoms and a significant lengthening of the lesion-free period (Lozada-Nur et al., 1994; Carbone et al., 1999). Such is the efficacy of clobetasol 17-propionate that it has changed the indications for systemic corticosteroid therapy in the treatment of severe erosive oral lesions (Lozada-Nur et al., 1991; González-Moles et al., 2002b,c, 2003). For example, 0.025% clobetasol propionate in orabase achieved complete remission in 62.5% of cases of symptomatic oral lichen planus (Lozada-Nur et al., 1991). Clobetasol propionate has also showed a greater and faster remission of pain and other symptoms compared with fluocinonide (Lozada-Nur et al., 1994; Carbone et al., 1999), a difference explained by the greater vasoconstrictor effect of clobetasol (Cornell and Stoughton, 1985; Stoughton, 1992). Vasoconstriction contributes to pain control by reducing the inflammatory response and possibly by inhibiting the local immune response (Lozada-Nur et al., 1994). González-Moles et al. (2002b,c) used 0.05% clobetasol propionate in aqueous solution and produced complete remission of pain and ulceration in 93% of patients with severe erosive oral lesions (Fig. 1). In a separate study, the same authors used a tray to apply clobetasol propionate and found complete remission of pain and ulcers in all patients with severe erosive gingival lesions (Fig. 2) (González-Moles et al., 2003). Nonetheless, treatment with clobetasol fails in a low percentage of cases (Lozada-Nur et al., 1991; González-Moles et al., 2002b,c), especially in patients with oral lichen planus associated with liver diseases (González-Moles et al., 2002b,c). Earlier reports (Jubert et al., 1966; Rebora et al., 1982; Lozada-Nur et al., 1984; Bagan et al., 1994; Cottoni et al., 1998) had demonstrated the difficulty of treating patients in whom systemic corticosteroid therapy is contraindicated. One author (Lozada-Nur et al., 1994) even reported a worsening of severe erosive oral lesions in two out of 60 patients treated with clobetasol propionate.
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Figure 1. Result of treatment of major aphthous ulcers. (A) Patient with major aphthous ulcers that completely responded (B) to treatment with an aqueous solution of 0.005% clobetasol propionate + 100,000 IU/cc nystatin.
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Figure 2. Result of treatment of mucous membrane pemphigoid. (A) Patient with gingival ulcerations as severe expression of mucous membrane pemphigoid that completely responded (B) to the use of 0.05% clobetasol propionate + 100,000 IU/cc nystatin in orabase paste applied with a tailor-made tray. A certain degree of gingival atrophy persists.
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Fluocinonide
Fluocinonide is a less potent TC than clobetasol propionate (Lozada-Nur et al., 1994). An ointment of 0.05% fluocinonide, mixed in equal parts with orabase paste and used 5–10 times a day to treat oral lichen planus, achieved a complete remission of symptoms in less than 20% of the patients (Silverman et al., 1991). Further evidence of the lower efficacy of fluocinonide in the treatment of erosive lesions was produced by a double-blind clinical trial that compared it with clobetasol propionate (Lozada-Nur et al., 1994). Although both drugs reduced the size of the ulcers with equal efficacy, fluocinonide was significantly less effective in reducing the pain.
In symptomatic oral lichen planus, 0.025% fluocinonide in an adherent vehicle produced complete remission of lesions and symptoms in 25% of patients (Carbone et al., 1999). Similar results were obtained by another group (Voute et al., 1993). However, we emphasize the scarcity of in-depth studies on the efficacy of fluocinonide in the treatment of erosive oral lesions.
(X.4) Very Highly Potent Steroids
There are few published reports on the use of other (mostly highly potent) TCs, although the few reports on the use of fluticasone propionate, betamethasone sodium phosphate (Hegarty et al., 2002), and momethasone furoate (Aguirre et al., 2004) have shown good results.
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(XI) FUTURE
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The clinical effectiveness of some corticosteroids of lower potency than clobetasol propionate needs to be studied. Thus, although a double-blind clinical trial showed that fluocinonide was less effective than clobetasol propionate (Lozada-Nur et al., 1994), no study has compared the application of these two drugs in aqueous solution. Consequently, a scientific study is required to evaluate the clinical results of applying fluocinonide in aqueous solution, because this would presumably improve its effectiveness and may have fewer effects that are less adverse in comparison with clobetasol propionate.
Received for publication April 8, 2004.
Accepted for publication September 3, 2004.
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Journal of Dental Research, Vol. 84, No. 4,
294-301 (2005)
DOI: 10.1177/154405910508400401
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ABSTRACT
(I) IMMUNOLOGICALLY MEDIATED...