see also: Lower Lip Bump (Mucocele) Minor Salivary Gland Traumatic Lesion with Histopathology

return to: Therapeutic Agents for Oral Mucosal Disease Treatment Strategies

Therapeutic Agents and Treatment Strategies for the Management

of Selected Mucosal Diseases

November 2018

Cindy Marek, PharmD & Faculty,

Dept. of Oral Pathology, Radiology & Medicine

The University of Iowa College of Dentistry

see footnote key at bottom of page below (e.g.3)

NOTE: EVERY PATIENT IS UNIQUE AND WE INDIVIDUALIZE ALMOST ALL THE EXAMPLES GIVEN IN THIS SECTION.

Chapped lips and baseline therapy for other lip problems

• Moisturizer: Lanolin
  • Use 3-4 times a day
  • Brand names Lansinoh^® or Purelan100^® (venture into the breast feeding aisle)
  • Ultra pure (HPA) brands are less allergenic and more efficacious than generic lanolin products
• Lip balm
  • PROBABLY NOT NECESSARY UNLESS GOING OUT IN THE WIND or SUN
  • Prefer Banana Boat^® Aloe with Vitamin E (SPF 45) or Blistex^® Complete Moisture^® (SPF 15)
  • Use when in sun or wind once or twice if in the sun frequently
  • Put this on immediately after the lanolin

Ulcerative conditions of the lips, including idiopathic, lichen planus, pemphigoid etc.

• Steroids (ointments on vermilion)
  • Use only nonfluorinated steroids and limit these steroids ONLY for inflammatory or ulcerative conditions confined to the lipstick portion of the lips
  • Rx: desonide 0.05%. Apply very thin layer to lips twice a day
  • PUT ON AFTER LANOLIN
  • DON’T apply to corners of lips
• Apply for three weeks or until the ulcer is gone 
  • Do not prescribe these products for use > 3 times per year
• If ulcer resolves but erythema remains, start decreasing the application of the steroid cream, per outline below or until erythema resolves
• First to once a day x 10-14 days, then every other day x 10-14 days, then every third day x 10-14 days
• If ulcer resolves without residual erythema steroids may be discontinued completely
• IF THE ULCER IS STILL THERE IN 3 weeks may consider short term ultrapotent steroid:
  • 1:1:1 Mixture of clobetasol 0.03% ointment and 2% mupirocin (Bactroban, g) ointment and clotrimazole 2% cream

Conditions of the lips occurring outside the vermilion border

• NON-STEROIDAL AGENTS IN PERIORAL/CIRCUMORAL REGION
  • Steroids are NOT indicated for circumoral or perioral dermatitis
  • Likewise angular cheilitis cases (covered below) only rarely requires anti-inflammatory agents
• Creams are preferred on skin surfaces
• In these areas outside the vermilion pimecrolimus or tacrolimus may be used
• NOTE: Due to the “black box” warning associated with these medications, this handout summary will not cover these. If clinician is familiar with restrictions and limitations they may be mixed and used with mupirocin and clotrimazole similar to the clobetasol 1:1:1 mixture above.
• Treatment of angular cheilitis
  • Use 2% clotrimazole cream and 2% mupirocin cream (mixed in 1:1 ratio)
    •    Apply to lip first thing in the morning and last thing at night
    •    After the morning application wait about a half hour to apply the lanolin or Blistex Complete Moisture if going outside.
• Don’t use the desonide while using this mixture unless consultation for complicating factors is performed. There are numerous cofactors including vertical dimension, obsessive compulsive disorders and perioral rhytides.

Footnote Key:

1. These medications are all contraindicated in microbial diseases. If given to patients with microbial diseases, microbial proliferation is usually enhanced and systemic dissemination is possible. Candidosis is a common side effect.

2. Systemic steroids are contraindicated or must be used with caution in a number of systemic conditions. Consultation with the patient's physician is recommended before prescribing. Tapering of prednisone is not necessary with 5-7 day burst therapy. Tapering of prednisone is not necessary with alternate day therapy (QOD) if the dosage does not exceed 20 mg QOD. In order to reduce the possibility of adrenocortical suppression, it is important that prednisone be taken in harmony with diurnal adrenocortical steroid levels. In order to accomplish this, prednisone should be taken 1-1/2 hours after normal arising time. Alternate day AM (QOD) dosage also reduces the possibility of adrenocortical suppression.

3. Whenever topical mouth rinses or ointments are prescribed, the manner in which the medication is used is very important. The patient should be advised that the medications are effective on contact and that they should avoid anything by mouth (NPO) for 1/2-1 hour after using them to prolong medication contact time.

4. Baseline hematology laboratory studies to include platelets are necessary to monitor possible bone marrow suppression.

5. Hepatotoxicity has been reported.                                                 OPRM Faculty

* Denotes prescription items that must be extemporaneously compounded by a pharmacist. Usually a specialty "compounding pharmacy" is a better choice as they have more experience and knowledge regarding product formulation.

Extemporaneously Compounding Medications for Intraoral Conditions

• Few products available in the U.S - ?? limited product demand
• Problems:
  • Difficulty with insurance payments, XIX & Medicare will not reimburse for the full cost
  • Expensive – Dental Pharmacy can mail Rxs to patients living in Iowa – at significantly less cost to patient patients and the products are formulated correctly for improved efficacy
  • “I can do that” - generalized lack of knowledge – many pharmacies incorrectly compound intraoral products causing mucosal irritation, reduced efficacy
• Make sure products are not flavored or sweetened (especially with sucrose) unless necessary!