Topical corticosteroids in association with miconazole and chlorhexidine in the long-term management of atrophic-erosive oral lichen planus: a placebo-controlled and comparative study between clobetasol and fluocinonide


Carbone, M.; Conrotto, D.; Carrozzo, M.; Broccoletti, R.; Gandolfo, S.; Scully, C.

Oral Diseases 5(1): 44-49

1999


To evaluate the efficacy of a combination of topical corticosteroids with topical antimycotic drugs in the therapy of atrophic-erosive forms of oral lichen planus (OLP). The study population consisted of 60 patients with OLP subdivided into three groups matched for sex and age. The first group (25 patients) and the second group (24 patients) received respectively 0.05% clobetasol propionate ointment or 0.05% fluocinonide ointment in an adhesive medium (4% hydroxyethyl cellulose gel) plus in each case antimycotic treatment consisting of miconazole gel and 0.12% chlorhexidine mouthwashes. The third group (11 patients), placebo group, received only hydroxyethyl cellulose gel and antimycotic treatment as above. All the treatment regimens were carried out for 6 months. Each patient was examined every 2 months during the 6-month period of active treatment and for a further 6 months of follow-up. Objective and subjective clinical progress was scored and compared between the three groups. Plasma cortisol levels were monitored in half the patients using the topical corticosteroids. All patients treated with clobetasol and 90% of the patients treated with fluocinonide witnessed some improvement, whereas in the placebo group only 20% of patients improved (P < 0.0001 and P = 0.00029, respectively. However, when considering complete responses, only clobetasol gave significantly better results than placebo. Clobetasol resolved 75% of the lesions whereas fluocinonide was effective in 25% of cases and placebo in none. Clobetasol achieved better results statistically than did fluocinonide (P = 0.00442) and placebo (P = 0.00049) whereas there was no statistical difference among fluocinonide and placebo (P = 0.140). Similar results were obtained for symptoms. Both drugs were shown to be effective in the treatment of erosive lesions, but clobetasol was considerably more efficacious than fluocinonide in the atrophic areas (75% vs 25% of total response, respectively) (P = 0.00442). None of the treated patients contracted oropharyngeal candidiasis. After 6 months of follow-up, 65% of the clobetasol-treated group and 55% of the fluocinonide group were stable. Estimation of plasma cortisol levels showed no significant systemic adverse effects of clobetasol or fluocinonide. Our results suggest that a very potent topical corticosteroid such as clobetasol may control OLP in most cases, with no significant adrenal suppression or adverse effects. Moreover, a concomitant antimycotic treatment with miconazole gel and chlorhexidine mouthwashes is a useful and safe prophylaxis against oropharyngeal candidiasis.

Oral
Diseases
(1999)
5,
44±49
1999
Stockton
Press
All
rights
reserved.
1354-523X199
$12.00
http://www.stockton-press.co.uk/od
Topical
corticosteroids
in
association
with
miconazole
and
chlorhexidine
in
the
long-term
management
of
atrophic-erosive
oral
lichen
planus:
a
placebo-controlled
and
comparative
study
between
clobetasol
and
_and
M
Carbone',
D
Conrottol,
M
Carrozzol,
R
Broccolettil,
S
Gandolfo',
C
Scully
2
'Department
of
Oral
Medicine,
School
of
Medicine
and
Dentistry,
University
of
Turin,
Italy;
2
Department
of
Oral
Medicine,
Eastman
Dental
Institute
and
Hospital
for
Oral
Health
Care
Sciences,
University
of
London,
London,
UK
OBJECTIVE:
To
evaluate
the
eilkacy
of
a
combination
of
topical
corticosteroids
with
topical
antimycotic
drugs
in
the
therapy
of
atrophic-erosive
forms
of
oral
lichen
planus
(OLP).
PATIENTS
AND
METHODS:
The
study
population
con-
sisted
of
60
patients
with
OLP
subdivided
into
three
groups
matched
for
sex
and
age.
The
erst
group
(25
patients)
and
the
second
group
(24
patients)
received
respectively
0.05%
clobetasol
propionate
ointment
or
0.05%
uocinonide
ointment
in
an
adhesive
medium
(4%
hydroxyethyl
cellulose
gel)
plus
in
each
case
antimycotic
treatment
consisting
of
miconazole
gel
and
0.12%
chlorhexidine
mouthwashes.
The
third
group
(II
patients),
placebo
group,
received
only
hydroxyethyl
cellulose
gel
and
antimycotic
treatment
as
above.
All
the
treatment
regimens
were
carried
out
for
6
months.
Each
patient
was
examined
every
2
months
during
the
6-
month
period
of
active
treatment
and
for
a
further
6
months
of
follow-up.
Objective
and
subjective
clinical
progress
was
scored
and
compared
between
the
three
groups.
Plasma
cortisol
levels
were
monitored
in
half
the
patients
using
the
topical
corticosteroids.
RESULTS:
All
patients
treated
with
clobetasol
and
90%
of
the
patients
treated
with
uocinonide
witnessed
some
improvement,
whereas
in
the
placebo
group
only
20%
of
patients
improved
(P
<
0.0001
and
P
=
0.00029,
respectively).
However,
when
considering
complete
responses,
only
clobetasol
gave
signietantly
better
results
than
placebo.
Clobetasol
resolved
75%
of
the
lesions
whereas
uocinonide
was
effective
in
25%
of
cases
and
placebo
in
none.
Clobetasol
achieved
better
results
statistically
than
did
uocinonide
(P
=
0.00442)
and
pla-
cebo
(P
=
0.00049)
whereas
there
was
no
statistical
differ-
ence
among
uocinonide
and
placebo
(P
=
0.140).
Similar
Correspondence:
Dr
Mario
Carbone,
Clinica
Odontostomatologica,
Corso
Dogliotti,
14
10126
Turin,
Italy.
Tel:
00
39
11
6632
563,
Fax:
00
39
11
6636
489
Received
6
January
1998;
revised
22
April
1998;
accepted
9
September
1998
results
were
obtained
for
symptoms.
Both
drugs
were
shown
to
be
effective
in
the
treatment
of
erosive
lesions,
but
clobetasol
was
considerably
more
eilkacious
than
uocinonide
in
the
atrophic
areas
(75%
vs
25%
of
total
response,
respectively)
(P
=
0.00442).
None
of
the
treated
patients
contracted
oropharyngeal
candidiasis.
After
6
months
of
follow-up,
65%
of
the
clobetasol-treated
group
and
55%
of
the
uocinonide
group
were
stable.
Esti-
mation
of
plasma
cortisol
levels
showed
no
signietant
systemic
adverse
effects
of
clobetasol
or
uocinonide.
CONCLUSIONS:
Our
results
suggest
that
a
very
potent
topical
corticosteroid
such
as
clobetasol
may
control
OLP
in
most
cases,
with
no
signietant
adrenal
sup-
pression
or
adverse
effects.
Moreover,
a
concomitant
antimycotic
treatment
with
miconazole
gel
and
chlorhexidine
mouthwashes
is
a
useful
and
safe
prophy-
laxis
against
oropharyngeal
candidiasis.
Keywords:
antimycotic
agents;
oral
lichen
planus;
therapy;
topical
corticosteroids
Introduction
Oral
lichen
planus
(OLP)
is
a
chronic
inflammatory
disease
affecting
0.5
to
1.5%
of
the
population
(Pindborg
et
al,
1972;
Salonen
et
al,
1990;
Scully
et
al,
1998).
Clinical
and
experimental
evidence
suggests
the
disease
may
be
of
immunological
pathogenesis
(Shiohara
et
al,
1986;
Walsh
et
al,
1990;
Gandolfo
et
al,
1994;
Carrozzo
et
al,
1996a),
findings
that
justify
the
use
of
immumodulators
and
immunosuppressors
in
the
control
of
the
disease
(Boyd
and
Nelder,
1991;
Carrozzo
et
al,
1996a).
OLP
is
currently
treated
with
corticosteroid
drugs
topically
(Cawson,
1968;
Tyldesley
and
Harding,
1977;
Lozada
and
Silverman,
1980;
Thongprasom
et
al,
1992;
Voute
et
al,
1993;
Lozada
Nur
et
al,
1994;
Rodstrom
et
al,
1994;
Carbone
et
al,
1996),
intralesionally
(Zegarelli,
1980)
or
systemically
(Silverman
et
al,
1985;
Carrozzo
et
al,
1996a).
Topical
preparations
afford
good
management
of
the
dis-
Long-term
management
of
OLP
M
Carbone
et
al
x
45
ease
without
exposing
the
patient
to
serious
side
effects
resulting
from
systemic
administration.
Among
the
topical
corticosteroids,
the
most
potent
are
also
the
most
lipophilic,
such
as
acetonide
derivatives
such
as
triamcinolone
aceton-
ide
and
many
more
hydrophobic
esters
like
betamethasone
dipropionate
or
clobetasol
propionate
(Guzzo
et
al,
1996).
Topical
corticosteroid
therapy
also
exposes
the
patient
to
the
risks
of
oropharyngeal
candidiasis
probably
related
to
local
immunosupression
(Thongprasom
et
al,
1992;
Lozada
Nur
et
al,
1994;
Rodstrom
et
al,
1994).
Some
have
rec-
ommended
the
concurrent
use
of
antifungals
(Brown
et
al,
1993;
Scully
et
al,
1998),
but
no
controlled
study
has
been
reported.
Moreover,
the
long-term
application
of
topical
corticosteroids
has
been
proposed
to
induce
a
higher
inci-
dence
of
remission
of
signs
and
symptoms
of
OLP
(
Lozada
and
Silverman,
1980;
Voute
et
al,
1993)
but
there are
no
data.
We
have
therefore
carried
out
a
controlled
study
using
two
topical
corticosteroids:
fluocinonide
and
clobetasol
pro-
pionate
applied
for
a
prolonged
period
of
6
months
to
evaluate
whether
long-term
treatment
achieves
a
longer
dis-
ease-free
period
after
use
of
the
drug
has
been
discontinued.
The
corticosteroids
were
used
along
with
miconazole
and
chlorhexidine,
both
antimycotics,
to
reduce
the
risk
of
oro-
pharyngeal
candidiasis.
The
patients
in
the
control
group
received
miconazole,
chlorhexidine,
and
a
hydroxyethyl
cellulose
gel
base
alone.
Materials
and
methods
Patients
The
study
involved
60
patients
(38
women,
22
men,
mean
age
60.87
±
10.23
years)
enrolled
on
the
following
inclusion
criteria:
(1)
presence
of
atrophic
and/or
erosive
lesions
of
the
oral
mucosa
for
at
least
6
months;
(2)
painful
lesions;
(3)
histological
confirmation
of
the
diagnosis
of
oral
lichen
planus
(WHO,
1978).
Subjects
were
excluded
from
the
study
if
they:
(1)
presented
with
histologic
signs
of
dysplasia;
(2)
had
been
taking
any
drugs
known
to
be
capable
of
inducing
lichenoid
reactions;
(3)
presented
also
with
cutaneous
or
genital
lesions;
(4)
had
previously
been
treated
for
OLP.
Subjects
were
subdivided
into
three
groups
matched
for
sex
and
age.
The
first
group
of
25
patients
(17
women,
8
men,
mean
age
61.2
±
10.74
years)
received
clobetasol
propionate
plus
antimycotics;
the
second
group
of
24
patients
(16
women,
8
men,
mean
age
60
±
9.57
years)
received
fluocinonide
plus
antimycotics;
the
third
group
had
11
patients
(7
women,
4
men,
mean
age
62
±
11.22
years)
who
received
a
placebo
and
antimycotics.
After
their
medical
history
was
recorded,
the
patients
underwent
hep-
atic
screening
as
published
elsewhere
(Gandolfo
et
al,
1994;
Carrozzo
et
al,
1996b).
Informed
consent
and
ethical
committee
approval
were
obtained
before
the
trial
started.
Treatment
protocol
Clobetasol
propionate
ointment,
0.05%
(Clobesol>
,
Glaxo,
Verona,
Italy)
and
0.05%
fluocinonide
ointment
(Topsyn>
,
Recordati,
Milano,
Italy)
were
each
mixed
separately
in
equal
parts
by
weight
in
a
4%
hydroxyethyl
cellulose
gel.
Clobetasol
propionate
was
applied
twice-daily
for
the
first
4
months
and
then
once-daily
for
the
following
2
months.
Fluocinonide
was
administered
three
times/daily
for
the
first
2
months,
then
twice-daily
for
the
next
2
months,
and
finally
once-daily
for
the
last
2
months.
All
the
patients
were
carefully
instructed
how
to
apply
the
ointments
on
dried
lesions
after
meals
and
not
to
eat,
drink
and
speak
for
at
least
an
hour
after
each
application.
All
patients
received
concomitant
antimycotic
treatment
as
prophylaxis
against
oropharyngeal
candidiasis.
This
consisted
of
miconazole
gel
(Micotef'
,
LPB,
Cinisello
B,
Milano,
Italy),
applied
once-daily,
oral
rinse
with
0.12%
chlorhexidine
(Plak-OuP
,
BYK
Gulden
Italia,
Cormano,
Milano,
Italy)
three
times/daily.
Half
the
subjects
randomly
assigned
to
cortico-
steroid
treatment
had
their
blood
cortisol
levels
and
blood
pressure
measured
at
baseline
and
after
4
months
of
treat-
ment.
The
control
group
received
hydroxyethyl
cellulose
two
times/daily
for
6
months
and
antimycotic
treatment
as
above.
Recording
of
signs
and
symptoms
and
follow-up
diary
Each
patient
receiving
the
active
corticosteroid
preparation
was
examined
at
the
beginning
of
the
treatment
and
then
every
2
months
during
each
6
month
period
of
treatment
and
of
follow-up.
The
patients
in
the
control
group
crossed
over
to
the
other
treatment
regimen
after
the
initial
6
months
of
therapy.
The
patient's
clinical
progress
was
recorded
at
each
visit
on
a
computerized
patient
chart
which
consisted
of
a
dia-
gram
of
the
oral
cavity
with
colour-coded
areas
for
hyper-
keratotic,
atrophic
or
erosive
lesions.
The
data
were
then
scored
according
to
the
criteria
scale
used
by
Thongprasom
et
al
(1992):
Score
5:
white
striae
with
erosive
area
>1
cm
2
Score
4:
white
striae
with
erosive
area
<1
cm
2
Score
3:
white
striae
with
atrophic
area
>1
cm
2
Score
2:
white
striae
with
atrophic
area
<1
cm
2
Score
1:
mild
white
striae
without
erythematous
or
eros-
ive
area
Score
0:
no
lesions
At
each
visit
the
patients
were
asked
to
evaluate
their
symptoms,
which
were
then
assigned
a
score:
Symptomatology
3:
serious
Symptomatology
2:
moderate
Symptomatology
1:
mild
Symptomatology
0:
no
symptoms
Complete
resolution
of
the
clinical
signs
was
defined
as
the
disappearance
of
all
atrophic-erosive
lesions
after
6
months
of
treatment
with
only
mild
white
striae
or
without
striae.
Scores
were
either
zero
or
one.
Complete
resolution
of
the
symptoms
was
defined
as
the
absence
of
any
discomfort
corresponding
to
zero
score.
Partial
resolution,
worsening
or
persistence
of
the
patient's
condition
meant
a
fall,
rise
or
no
change
in
the
patient's
score. Separate
clinical
Long-term
management
of
OLP
M
Carbone
eta!
46
Table
1
Comparisons
of
signs
among
patients
with
oral
lichen
planus
treated
with
clobetasol,
fluocinonide
and
placebo
Clinical
response
Group
Clobetasol
Fluocinonide
Controls
(n
=
20)
(n
=
20)
(n
=10)
Cured
15
(75%)
5
(25%)
0
Uncured
5
(25%)
15
(75%)
10
(100%)
*0.00442
**0.1400
*0.00043
Chi-square
test
with
Yates'
correction;
**Fisher's
exact
test
Table
2
Comparisons
of
symptoms
among
patients
with
oral
lichen
planus
treated
with
clobetasol,
fluocinonide
and
placebo
Clinical
response
Group
Clobetasol
Fluocinonide
Controls
(n
=
20)
(n
=
20)
(n
=10)
No
symptoms
16
(80%)
6
(20%)
1
(10%)
Symptoms
4
(20%)
14
(80%)
9
(90%)
*0.00423
**0.3717
*0.00041
Chi-square
test
with
Yates'
correction;
**Fisher's
exact
test
responses
of
erosive
and
atrophic
lesions
to
the
active
treat-
ment
(with
fluocinonide
and
clobetasol)
was
also
evaluated
comparing
the
frequency
of
cured
lesions
among
the
two
groups.
Statistical
analysis
Chi-square
test
with
Yates'
correction
or
Fisher's
exact
test
were
used
to
compare
responses
between
the
groups.
This
analysis
was
performed
by
means
of
EPI-INFO
version
5
(Dean
et
al,
1990).
P
values
of
<0.05
were
considered
stat-
istically
significant.
Results
The
most
frequently
affected
area
of
the
mouth
was
the
buccal
mucosa
(83%
of
patients),
followed
by
the
tongue
(38.9%),
the
gingiva
(27.1%),
the
vermilion
(8.4%),
the
edentulous
ridge
(6.75),
the
palate
(3.3%),
and
the
floor
of
the
mouth
(1.7%).
Thirty-five
percent
of
patients
had
abnormal
liver
function
tests:
28%
tested
serologically
positive
for
hepatitis
C
virus
(Gandolfo
et
al,
1994;
Car-
rozzo
et
al,
1996b).
Other
concurrent
diseases
found
were:
hypertension
(25%),
diabetes
(10%),
gastritis
or
gastric
ulcer
(8.4%),
arthralgia
(6.7%),
cardiac
ischemia
(5%),
and
pulmonary
emphysema
(3.3%).
Of
the
60
patients
initially
enrolled
in
the
study,
50
com-
pleted:
10
patients
were
dropped
during
the
study
because
of
missed
follow-up
or
incomplete
results.
All
patients
treated
with
clobetasol
witnessed
some
improvement,
whereas
two
patients
treated
with
fluocinonide
(10%)
had
no
beneficial
response
to
treatment.
In
the
placebo
group,
20%
of
patients
had
some
improvement,
70%
showed
no
changes.
The
differences
in
results
between
the
clobetasol
and
the
fluocinonide
groups
and
the
placebo
group
were
both
statistically
significant
(P
<
0.0001
and
P=
0.00029,
respectively,
Fisher's
exact
test),
but
when
we
considered
complete
responses,
only
clobetasol
gave
better
results
than
placebo.
Clobetasol
gave
complete
remission
in
75%
of
the
patients,
whereas
fluocinonide
was
effective
in
25%
and
placebo
in
none.
Clobetasol
achieved
better
results
statisti-
cally
than
did
fluocinonide
(x
2
=
8.10,
P=
0.00442)
and
placebo
(P
=
0.00049,
Fisher's
exact
test)
whereas
there
was
no
statistical
difference
between
fluocinonide
and
pla-
cebo
(P
=
0.140,
Fisher's
exact
test)
(Table
1
).
Simi-
larly,clobetasol
gave
better
results
statistically
than
did
fluocinonide
and
also
placebo
for
symptoms
(x
2
=
8.18,
P=
0.00423
and
P=
0.00041,
respectively)
whereas
fluoc-
inonide
did
not
(Table
2).
Both
drugs
were
shown
to
be
effective
in
the
treatment
of
erosive
lesions,
where
clobetasol
proved
slightly
more
so
(100%)
than
fluocinonide
(81%)
(P
=
0.2380,
Fisher's
exact
test)
(Figures
1
and
2).
Fluocinonide
was
also
seen
to
be
less
active
in
the
atrophic
areas
(25%
of
total
response),
where
clobetasol
was
considerably
more
effec-
tive
(75%
of
total
response)
(x
2
=
8.10,
P=
0.0044).
None
of
the
treated
patients
contracted
oropharyngeal
candidiasis.
The
local
side
effects
reported
were:
extrinsic
staining
of
the
teeth
(100%
of
cases)
and
alteration
of
the
sense
of
taste
(82%).
Both
these
side
effects
spontaneously
Table
3
Responses
from
follow-up
study
of
oral
lichen
planus
patients
treated
with
clobetasol
and
fluocinonide
Original
response
Course
of
disease
Drug
2
months
of
follow-up
4
months
of
follow-up
6
months
of
follow-up
Unchanged
Worsened
Unchanged
Worsened
Unchanged
Worsened
Cured
Clobetasol
(n
=
15)
13
2
13
0
11
2
Fluocinonide
(n
=
5)
5
0
5
0
5
0
Uncured
Clobetasol
(n
=
5)
5
0
3
2 2
Fluocinonide
(n
=
15)
12
3
9
3
6
!:;
ALL
k
m
Long-term
management
of
OLP
M
Carbone
et
al
.
1
6
111
I
47
F
4
.;
.
r
r
I
IL
r
I
-
'gm
Figure
2
(a)
Patient
no.
21
(clobetasol
group)
with
lingual
atrophic
eros-
ive
lichen
planus.
(b)
After
2
months
of
therapy
with
clobetasol,
chlorhexi-
dine
and
miconazole,
there
are
only
mild
hyperkeratosic
lesions
steady
clinical
status
(75%).
This
number
fell
to
12
(60%)
after
4
months,
and
to
11
(55%)
after
6
months
(Table
3).
1-
Figure
1
(a)
Patient
no.
13
(clobetasol
group)
with
atrophic
and
erosive
lichen
planus
of
buccal
mucosa.
(b)
After
2
months
of
therapy
with
clobet-
asol,
chlorhexidine
and
miconazole,
slight
atrophic
areas
are
still
appreci-
able.
(c)
The
same
patient
after
6
months
from
suspension
of
therapy
reversed
after
the
end
of
treatment.
The
blood
cortisol
lev-
els
remained
stable
during
the
entire
course
of
therapy,
but
one
patient
experienced
a
transient
hypertensive
event
(blood
pressure
180/95
mm
Hg).
In
the
clobetasol-treated
group,
18
patients
(90%)
were
stable
after
2
months,
16
(80%)
after
4
months,
and
13
(65%)
after
6
months
(Table
2).
After
2
months
follow-up,
15
of
the
20
patients
treated
with
fluocinonide
achieved
a
Discussion
Our
controlled
study
showed
a
significant
improvement in
the
condition
of
patients
affected
by
atrophic-erosive
oral
lichen
planus
treated
with
potent
topical
corticosteroids.
Both
clobetasol
and
fluocinonide
achieved
good
results
vs
the
control
group
treated
without
corticosteroids.
However
clobetasol
produced
better
improvements
in
both
signs
and
symptoms
compared
with
fluocinonide,
despite
it
being
administered
in
lower
doses.
The
efficacy
of
clobetasol
shown
here
confirms
previous
reports
(Lozada
et
al,
1994;
Rodstrom
et
al,
1994)
on
fluocinonide
(Lozada
et
al,
1980;
Thongprasom
et
al,
1992;
Voute
et
al,
1993;
Lozada
Nur
et
al,
1994;
Carbone
et
al,
1996)
but
only
one
study
has
compared
the
two
(Lozada
Nur
et
al,
1994).
However,
in
contrast
with
our
data,
this
latter
study
did
not
find
a
sig-
nificant
difference
in
clinical
response
between
clobetasol
and
fluocinonide
but
it
included
patients
affected
by
oral
vesiculoerosive
diseases
other
than
OLP.
On
the
other
hand,
our
complete
response
rate
in
the
fluocinonide-treated
patients
(25%)
is
quite
similar
to
that
(20%)
published
by
Voute
et
al (1993),
despite
the
longer
usage.
All
these
data
Long-term
management
of
OLP
M
Carbone
et
al
48
suggest
that
more
frequent
and
longer
usage
do
not
signifi-
cantly
increase
the
incidence
of
remissions.
Generally,
the
more
potent
the
steroid
and
the
longer
the
treatment,
the
higher
the
risk
for
Candida
infection
(Thongprasom
et
al,
1992;
Lozada
Nur
et
al,
1994;
Rod-
strom
et
al,
1994).
The
adverse
effects
from
our
regimen
were
minimal.
Interestingly,
none
of
our
patients
presented
with
signs
of
oropharyngeal
candidosis
even
after
6
months
of
treatment,
the
antimycotics
clearly
being
efficacious.
The
blood
cortisol
levels
were
stable
suggesting
little
if
any
effect
of
the
drugs
on
the
hypothalamus-hypophyseal-
adrenal
axis,
as
suggested
by
others
(Allenby
et
al,
1975;
Weston
et
al,
1988;
Plemons
et
al,
1990).
The
single
hyper-
tensive
event
occurred
in
a
patient
with
a
history
of
similar
problems
and
thus
cannot
be
attributed
to
the
therapy.
The
only
local
side
effects
were
those
that
could
be
linked
to
prolonged
use
of
chlorhexidine:
extrinsic
staining
of
the
teeth
and
alteration
of
the
sense
of
taste.
These
effects
reversed
spontaneously
and
did
not
lead
to
discontinuation
of
the
therapy
in
any
cases.
The
need
to
treat
Candida
infection
is
controversial.
The
presence
of
Candida
mycetes
in
lichen
lesions
remains
a
debated
issue
(Holmstrup
and
Dabelsteen,
1974;
Lundstrom
et
al,
1984;
Simon
and
Hornstein,
1980;
Krogh
et
al,
1987;
Hatchuel
et
al,
1990;
Serra
et
al,
1996),
but
some
authors
have
reported
obtaining
considerable
improvement
in
the
clinical
condition
and
symptomatology
of
patients
treated
with
topical
antimycotics
(Lundstrom
et
al,
1984).
The
con-
trol
group
in
the
present
study
received
hydroxyethyl
cellu-
lose,
chlorhexidine
and
miconazole
for
6
months
and
reported
no
substantial
benefits
from
this
treatment.
This
finding
suggests
that
Candida
plays
a
marginal
role,
if
any,
in
this
disease.
Proposed
as
a
useful
drug
in
the
treatment
of
other
inflammatory
diseases
of
the
oral
cavity
(Miles
et
al,
1993),
in
the
present
study
chlorhexidine
was
shown
not
to
be
active
against
atrophic-erosive
lichen
planus,
even
if
used
for
prolonged
periods,
as
shown
by
the
lack
of
efficacy
in
our
controls.
In
our
follow-up
study,
at
12
months
65%
of
the
clobeta-
sol-treated
group
and
55%
of
the
fluocinonide-treated
group
maintain
improvement.
In
a
study
conducted
by
Lozada
and
Silverman
(1980)
where
the
patients
were
treated
for
2
weeks
with
fluocinonide,
after
10
months
only
22%
of
those
who
had
discontinued
applying
the
drug
were
stable.
In
a
study
conducted
by
Thongprasom
et
al
(1992)
on
patients
receiving
either
fluocinonide
or
triamcinolone
for
24-32
weeks,
less
than
6%
were
free
of
disease
after
12
months.
Thus,
compared
to
the
results
of
these
two
studies,
our
data
suggest
that
the
long-term
use
of
potent
drugs,
particularly
clobetasol,
may
help
control
the
disease,
and
offer
substantial
disease-free
periods beyond
the
end
of
active
treatment.
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