Oral Lichen Planus Treated With Apremilast

A second case involved a 71-year-old female with OLP, confirmed by biopsy 4 years prior to presenting to my practice. She had been treated with topical steroids but remained symptomatic. She had also been prescribed methylprednisolone, which she used intermittently for several months, followed by 40 days of hydroxychloroquine. She continued to experience persistent flares of her mouth sores, and discontinued these oral therapies due to concern over safety and inadequate efficacy. At the time I saw her, her mouth sores were worsening on topical therapy alone.

Upon starting apremilast 30 mg twice daily, she experienced mild nausea and diarrhea following the titration phase. During her 2-week follow-up visit, she was instructed to reduce the dose to 30 mg once daily for the next 2 weeks to minimize the likelihood of side effects. At her next follow-up visit at 4 weeks after initiating apremilast, her mouth sores had cleared and she was no longer experiencing nausea. She wished to remain on once-daily dosing but was instructed to increase the dosage to twice daily if she experienced flares. At present, she has been taking 30 mg apremilast once daily for 6 months and remains in good control, with only minimal erythema of the oral mucosa and no oral discomfort. She has not needed to increase the dose due to flares.

A 66-year-old female presented to my practice with erythematous and lichenoid papules on her arms and legs. A biopsy taken from her wrist confirmed a diagnosis of lichen planus, and the patient was prescribed a Class II topical corticosteroid. Upon her return to the clinic 2 months later, her skin lesions showed substantial improvement, but she mentioned that she had visited an oral surgeon due to soreness in her mouth. This physician had diagnosed OLP and recommended triamcinolone paste. The topical corticosteroid did not provide relief from the discomfort of eating. A physical examination revealed moderate erythema of the lateral oral mucosa and erosions.

I prescribed apremilast, and the patient has been taking the full 30 mg twice-daily dose for 3 months. During her most recent visit, her mouth was completely clear and free of sores, and she had no pain upon eating. She is extremely happy with her results. The treatment plan is to continue apremilast indefinitely, in view of the chronic nature of lichen planus, but perhaps tapering the dose to once daily.

OLP can be refractory to treatment and adversely affects patients’ quality of life. The primary aims of therapy for this chronic condition are resolution of painful symptoms, healing of oral mucosal lesions, and maintenance of good oral hygiene. Although there is no specific treatment, topical preparations, including corticosteroids and immunosuppressives, are typically used first-line to provide symptomatic relief. Systemic therapies are used for more difficult cases, although flares can be anticipated, even with systemic treatments. Apremilast, an immunomodulator used for psoriasis, was effective in treating