Q U I N T E S S E N C E I N T E R N AT I O N A L
ORAL MEDICINE
Sung-Hee Jeong
Topical sulfasalazine for unresponsive oral lichen planus Sung-Hee Jeong, DMD, MSD, PhD1/Hee-Sam Na, MD, MSD, PhD2/Su-Hyeon Park, DDS3/Yong-Woo Ahn, DDS, MSD, PhD 4/Jin Chung, DDS, MSD, PhD5 Objective: The purpose of this study was to evaluate the usefulness of topical sulfasalazine in the treatment of oral lichen planus (OLP) resistant to corticosteroid therapy. Method and Materials: Twenty-one unresponsive OLP patients were treated with topical sulfasalazine 3 times a day for 4 weeks. Each patient’s symptoms and lesion size were evaluated at the beginning of therapy, and then after 4 weeks to determine the efficacy of topical sulfasalazine. Inflammatory cytokines levels in saliva were measured by ELISA. Results: Seventeen patients
(81%) reported improvement of discomfort and 12 patients (57%) had lesions decrease in size over 50%. Patients who had higher levels of IL-1β and IL-8 were more responsive to topical sulfasalazine therapy. Conclusion: Topical sulfasalazine should be considered when OLP does not respond to corticosteroid therapy. Furthermore, high concentrations of IL-1β and IL-8 in the saliva are useful indicators for the application of topical sulfasalazine in OLP patients refractory to steroid treatment. (Quintessence Int 2016;47:319–327; doi: 10.3290/j.qi.a34974)
Key words: sulfasalazine, topical application, unresponsive oral lichen planus
Oral lichen planus (OLP) is a chronic inflammatory disease that affects the mucosal membrane. T-cell mediated damage against the mucosal epithelial cells is implicated in the pathogenesis of OLP,1,2 although the exact mechanism is unknown. Clinical forms of OLP include reticular, papular, plaque-like, erosive, atrophic, and bullous types of lesions.2 Patients who have erosive lesions usually com1
Associate Professor, Department of Oral Medicine, School of Dentistry, Pusan National University, Dental Research Institute, Yangsan, Republic of Korea.
2
Assistant Professor, Department of Oral Microbiology, School of Dentistry, Pusan National University, Yangsan, Republic of Korea.
3
Postgraduate Student, Department of Oral Medicine, School of Dentistry, Pusan National University, Dental Research Institute, Yangsan, Republic of Korea.
4
Professor, Department of Oral Medicine, School of Dentistry, Pusan National University, Dental Research Institute, Yangsan, Republic of Korea.
5
Professor, Department of Oral Microbiology, School of Dentistry, Pusan National University, Yangsan, Republic of Korea.
Correspondence: Dr Jin Chung, Department of Oral Microbiology, School of Dentistry, Pusan National University, Beomeo-ri, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, 626-770, Republic of Korea. Email: [email protected]
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plain more of soreness and difficulties with eating, drinking, tooth brushing, and speaking than other forms of OLP.3 Several immunosuppressants including corticosteroid, cyclosporine,4 and tacrolimus5 are widely used to reduce pain and inflammation in OLP patients. Topical applications are used primarily because they are easy to apply and have potent effects on local lesions. In the absence of response of topical medications, intralesional injection or systemic administration should be considered. Regardless of administration route, several side effects of these drugs have been reported, limiting their clinical use.6 Therefore, patients with refractory OLP need new treatments that are more effective but have fewer side effects. Sulfasalazine is extensively used in inflammatory bowel disease and is effective on immune-related inflammatory disease such as Crohn’s disease, rheumatoid arthritis, and Behcet’s disease. In spite of its effectiveness, the anti-inflammatory mechanism is not
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clearly understood. When orally administered, sulfasalazine is metabolized into 5-aminosalicylic acid (5-ASA) and sulfapyridine in the intestine. Sulfapyridine is known to have antimicrobial effects,7,8 whereas 5-ASA has anti-inflammatory actions.9 Sulfasalazine is effective for dermatologic diseases including psoriasis,10 alopecia areata,11 and even lichen planus (LP).12 Sulfasalazine has been suggested as a therapeutic option that has no major adverse effects in the treatment of LP.12,13 However, oral administration of sulfasalazine was not effective on mucosal LP and there has been no other attempt using topical application with this medicine. Thus, in the present study, we assessed the effect of topical application of sulfasalazine in patients with symptomatic OLP resistant to corticosteroid therapy.
METHOD AND MATERIALS Ethics This study was an open-trial investigation and was approved by the Pusan National University Hospital Ethics Committee (2010079). The protocol and consent forms were approved by the Ministry of Food and Drug Administration in Korea and registered to the Clinical Research Information service of Korea National Institute of Health (http://cris.nih.go.kr-KCT0000665).
Subjects Between 2010 and 2011, 210 patients were diagnosed with OLP based on clinical and histologic findings, and received treatment with corticosteroids at Pusan National University Dental Hospital, Republic of Korea. Steroid therapy was performed by topical application or oral administration. In most cases, initial steroid therapy was performed by topical dexamethasone (0.05%) in the form of a mouthwash. After that, prednisolone mouthwash (30 mg/500 mL), dexaltin ointment (0.1% dexamethasone), or triamcinolone acetonide ointment (0.1%) was used depending upon the severity of lesions. Prednisolone was administered orally when the lesions failed to improve after the initial treatments. Patients taking medication for or having a history of
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immune-related diseases like atopic eruption, rheumatoid arthritis, skin lichen planus, or colitis were excluded. For this study, we selected patients whose symptoms appeared to be over a numerical analog scale (NAS, range 0–10) of 4 regardless of the lesion type, although the conditions alternated between improving and worsening repeatedly. Twenty-one patients among those selected were finally recruited into this study (Table 1). All the patients agreed to this trial and were given a full description about sulfasalazine and its procedure. All patients provided informed written consent. The patients were asked to maintain proper plaque control with commercially available dentifrice without sodium lauryl sulfate (SLS-free dentifrice), and they had a wash-out period of 2 weeks. The treatment solution contained 30 mg of sulfasalazine (Hanlim Pharm) in 5 mL of distilled water and was applied three times a day for 3 to 5 minutes and then expectorated. The patients were requested not to eat or drink for 30 minutes afterwards and were restricted from using any other medication. The primary outcome measure was based on the disease severity and the sizes of the lesions which were also measured in the patients with secondary outcomes of symptom changes. The severity of lesions were recorded following the criteria scale by Thongprasom et al14 as follows: • 0 = no lesion/normal mucosa • 1 = mild white striae/no erythematous area • 2 = white striae with atrophic area 1 cm2 • 4 = white striae with erosive area 1 cm2. The patients were grouped based on three levels: mild (0,1), moderate (2,3), and severe (4,5). To evaluate the changes of symptoms, patients were asked to use a NAS, and the lesions were recorded using a transparent grid divided into calibrated 2 mm2 that was placed over the lesion and traced. We measured the lesion size within the boundary of the whole lesion which included the white striae, erythema, and erosion.
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Table 1
Clinical information of OLP patients before topical sulfasalazine application
Patient
Sex/ age
Time of illness (days) at first visit
Location of lesions
Type of OLP
1
F/45
2
F/50
120
B,V
R,A
120
G,B,V
R,A
3
M/39
50
4
F/38
150
B,V
R,A,E
B
R,A
5
F/42
6
F/56
365
B,V
R,A
395
G,B,V
R,A,E
7 8
F/61
60
G,B,V
R,A,E
F/54
120
B
R,A,E
9
F/48
90
B,V
R,A
10
F/45
365
B,V
11
F/43
180
G,B,V
12
F/36
30
13
F/50
120
14
M/49
15
F/47
730
16
F/39
30
17
F/49
18
M/40
19
F/56
20
F/40
30
21
F/58
150
Duration of steroid therapy (days)
NAS*
Severity of lesions
Size of lesions (mm2)
228
5
Moderate
164
225
5
Mild
312
48
5
Moderate
336
3,440
5
Mild
100
64
5
Mild
508
273
5
Severe
240
239
4
Severe
288
760
5
Severe
336
116
5
Mild
264
R,A
49
5
Mild
102
R,A
293
4
Mild
132
G,B,V
R,A
90
5
Moderate
320
B
R,A
69
6
Mild
160
B,T
R,A,E
72
7.5
Severe
316
G
R,A
160
4
Mild
92
B,V
R,A
237
5
Mild
52
150
G,V
R,A
293
5
Mild
84
120
B,V
R,A
141
6
Mild
180
120
G,B,V
R,A
768
5
Mild
769
G,B,V,T
R,A
47
5
Mild
64
G,V
R,A
481
6
Mild
78
3,650
A, atropic form; B, buccal mucosa; E, erosive form; G, gingiva; R, reticular form; T, tongue; V, vestibule. *NAS, numerical analog scale (range 0–10) at the first day application.
This evaluation was recorded weekly before and after using topical sulfasalazine. All the patients were treated for 4 weeks and further followed for 4 weeks after finishing the application. After these experiments, the severity of lesions and NAS were recorded whenever they visited the clinic. Thirty healthy volunteers took the same topical sulfasalazine as a control. We recorded statements about taste, flavor, sensation, and any influence on oral mucosa. There are two controls within this experimental protocol: first the patients themselves who were on steroid prior to the sulfasalazine, and second the healthy volunteers on sulfasalazine. The healthy volunteers served as a control for side effects and cytotoxic effects. The patients who were on steroids before served as a paired control for comparison of treatment.
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Collection of saliva and cytokine ELISA The whole unstimulated saliva (WUS) of the experimental patients and healthy volunteers was collected at every visit between 9:00 and 11:00 a.m. The subjects refrained from eating and drinking for 1 hour prior to the collection. All subjects were asked to tilt their head forward, and then drooled WUS into a sterile tube without swallowing for 5 minutes. All the samples were immediately frozen at −80°C until usage. The protein levels of interleukin 1β (IL-1β) and IL-8 in the saliva were analyzed by using an ELISA kit from eBioscience. Standard or saliva was added to an ELISA well plate pre-coated with specific monoclonal capture antibody. After incubating for 2 hours at room temperature, anti-IL-1β and anti-IL-8 antibody conjugated with biotin was added. After incubation for 1 hour at
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Lesion decrease (%)
100 80 60 40 20 0
0
1 2 NAS change
>3
Fig 1 Correlation between lesion size % change and NAS score change during topical sulfasalazine treatment. NAS scores and lesion size were measured weekly before and during treatment.
room temperature, streptavidin conjugated with horseradish peroxidase was added to the solution. Substrate solution containing chromogen was added and allowed to react for 30 minutes. The levels of cytokines were assessed by a microelisa reader at 450 nm.
Statistical analysis Data were analyzed using Prism GraphPad v5 (GraphPad Software). The Mann-Whitney U test was used to compare nonparametric unpaired data. The null hypotheses of no difference were rejected if P values were less than .05.
RESULTS Clinical results The sulfasalazine mouthwash had an astringent taste without any flavor, and had shown no specific sensation at the oral mucosa as reported by normal healthy volunteers. It had no influence on the oral mucosa of healthy participants during the 4 weeks of application. However, sulfasalazine mouthwash showed yellow stains on the tongue due to the color of the suspension, but this disappeared over time. Twenty-one patients with OLP resistant to steroid therapy were recruited and treated with topical sulfasalazine for 4 weeks. Study subject information is described in Table 1. OLP patients included three males
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and eighteen females aged between 36 and 61 years (mean age 46.9 years). Duration of illness by records at first visit ranged from 30 days to 10 years (mean time 11.3 months) and NAS was recorded at 4 to 7.5 at the beginning of sulfasalazine treatment. The lesion locations were anywhere on the oral mucosa including buccal mucosa, vestibule, tongue, or gingiva. The included lesions were symptomatic reticular, atropic, erosive/ulcerative, or mixed form of OLP and severity of lesions ranged from mild to severe (Table 1). Most patients with clinical symptom improvements reported early resolution of discomfort within 2 weeks after topical application of sulfasalazine. As shown in Fig 1, 17 patients (81%) displayed improved NAS changes ranged from 1 to 5. Twelve patients (57%) had lesions decrease in size over 50%. Eleven patients (52%) had lesions diminish over 50% and NAS decrease simultaneously (Fig 1). Figure 2 shows representative images of improved patients. The first case was the 15th patient, who had been treated with steroid therapy for 5 months without any improvement. After 4 weeks of topical sulfasalazine application, the white striae and atropic lesion on the maxillary right gingiva diminished and discomfort decreased (Fig 2a). At the last visit after 16 weeks, the patient reported that the NAS score went down to zero (see Fig 4b). In Case 7, the patient had been treated with steroid for 8 months without any improvement. After 4 weeks of topical sulfasalazine application, the size of the lesion on the right buccal mucosa diminished and discomfort decreased at 4 weeks without any additional application (Fig 2b). At the last visit after 3 weeks, the patient reported that the NAS score went down to 0.5 (see Fig 4a).
Cytokines in saliva To determine factors more favorable for sulfasalazine treatment, information including sex, age, type of OLP, time of illness, duration of steroid therapy, and pro-inflammatory cytokines in saliva was analyzed. Sex, age, type of OLP, time of illness, and duration of steroid therapy were not associated with NAS or lesion size
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a
c
b
d
e
Figs 2a to 2e Representative images of improved patients. (a and b) Clinical photos of case 15. This patient was treated with steroid for 5 months. (a) Maxillary right gingiva before treatment with sulfasalazine; (b) after 4 weeks application of topical sulfasalazine. (c and d) Clinical photos of case 7. This patient was treated with steroid for 8 months. (c) Right buccal mucosa before treatment with sulfasalazine, (d) after 4 weeks application of topical sulfasalazine, and (e) 2 weeks after final treatment.
change (Table 2). Among various pro-inflammatory cytokines, IL-1β and IL-8 were significantly increased in OLP patients compared to healthy subjects in the preliminary study (results not shown). There was also a positive correlation between NAS change and pro-inflammatory cytokine level. Patients whose NAS improved by more than 3 (group 1) showed significantly higher salivary IL-1β and IL-8 levels than those whose NAS improved less than 3 (group 2) (Table 2 and Fig 3). Moreover, as shown in Fig 3c, salivary IL-1β and IL-8 are closely correlated (r = 0.8713). However, when cytokine levels in saliva were analyzed throughout the treatment, no significant change was observed (results
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not shown). There was no correlation between pro-inflammatory cytokine level and lesion size or lesion size change percent (results not shown).
DISCUSSION OLP is a chronic inflammatory disease and the exact pathologic process is unknown, although research indicates that OLP is a T-cell mediated autoimmune disease.15-17 Steroids are considered the first-line treatment for OLP, especially as topical application. Other topical agents such as tacrolimus, pimecrolimus, cyclosporine, and aloe vera have been tried.18 However, these had a
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Table 2
Summary of OLP patients treated with topical sulfasalazine grouped by NAS* change
Sex Age (y)
Group 1†
Group 2‡
5F, 1M
11F, 2M
49.0 ± 10.4
Time of illness (mo)
P value
49.1 ± 11.3
.8761
2.5 ± 1.5
15.3 ± 29.6
.3110
318.8 ± 263.3
418.5 ± 854.3
.7849
Before
5.3 ± 0.5
5.3 ± 0.9
.8268
After
1.5 ± 1.0
4.4 ± 0.9
.0006**
257.5 ± 264.1
268.5 ± 159.3
.4594
81.3 ± 85.2
140.6 ± 103.6
.1727
65.5 ± 23.8
50.1 ± 13.7
.1098
IL-1β (pg/mL)
336.0 ± 201.3
154.0 ± 68.9
.0216**
IL-8 (pg/mL)
419.1 ± 173.1
230.6 ± 141.0
.0176**
Duration of steroid therapy (d) NAS Before Size of lesion (mm2) After Size decrease %
*NAS, numerical analog scale, range 0–10. **P < 0.05. †Group 1: NAS decreased more than 3 (n = 6). ‡Group 2: NAS decreased less than 3 (n = 15).
similar or less effect than corticosteroids. When OLP patients do not respond to steroid therapy, few substitutes offer cure. Sulfasalazine is used for ulcerative colitis, Crohn’s disease, and is a second-line drug for rheumatoid arthritis. Sulfasalazine is also suggested as a therapeutic option in the treatment of LP without major adverse effects.12,13 However, oral application of sulfasalazine was not effective on mucosal LP. When orally administered, sulfasalazine is metabolized into 5-ASA and sulfapyridine by azoreductase of gut microbiota. Among various bacteria, Lactobacillus acidophilus, Bifidobacterium lactis, and Streptococcus salivarius possess azoreductase activity.19 In the oral cavity, Streptococcus species including S salivarius comprise the majority of oral microbiota. Therefore, it was hypothesized that drug directly applied to the oral mucosa could be effective in treating refractory OLP. To titrate the dosage of topical sulfasalazine, trials were performed with three different dosages: 500 mg/5 mL, 200 mg/5 mL, 30 mg/5 mL. Healthy subjects did not report any discomfort or mucosal changes. However, OLP patients felt a burning sensation to topical sulfasalazine in the 500 mg/5 mL and 200 mg/5 mL solutions, but not the 30 mg/5 mL dose. Therefore, we selected the
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30 mg/5 mL for application dosage and expected to get no systemic effects after swallowing as the dosages were nowhere close to those used for other diseases. The patients enrolled in this study were previously treated with steroids without satisfactory results. Some patients with steroid therapy showed improvement, while others did not feel any improvement. Therefore, we chose patients treated with steroids whose NAS did not decrease below 4. Among them, we selected volunteers for the study, and 21 patients were selected for topical application of sulfasalazine. The type of lesions was not considered. Most of the patients tolerated the treatment of topical sulfasalazine well. Some patients complained of some discomfort such as a mild burning sensation at the first week and yellow discoloration on oral mucosa that disappeared after treatment. There were no major side effects such as systemic influence and cutaneous changes. After the application of topical sulfasalazine, patients reported the improvement of the feeling of constriction during mouth opening and hypersensitivity to hot or spicy food. Seventeen patients (81%) displayed improved NAS changes and twelve patients (57%) had lesions decrease in size over 50%. Omidian et al13 found systemic administration of maximum 2.5 g/
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800
800 P = 0.010
600
IL-8 (pg/ml)
IL-1β (pg/ml)
P = 0.0038
400
200
600
400
200
0
Group 1
0
Group 2
a
Group 1
Group 2
b
IL-8 (pg/ml)
800 600 r2 = 0.7591
400 200 0 0
c
200
400 IL-1β (pg/ml)
600
800
day sulfasalazine effective on pruritic lesions, but ineffective on mucosal lesions. As shown in the results of the present study, a little amount of topical application of sulfasalazine on oral mucosal lesions could be more effective than oral administration. Oral fluid analysis could be used in the monitoring of diseases, and the results correlate with those from blood.20 The initiation and progression of oral disease are mediated by inflammatory response, and cytokines are well known inflammatory mediators. Pro-inflammatory cytokines have been detected in oral fluid of the patients with Sjögren’s syndrome, OLP, oral leukoplakia, and oral squamous carcinoma.21 High concentrations of nuclear factor κB (NF-κB)-dependent cytokines including tumor necrosis factor α (TNF-α), IL-1α, IL-6, and IL-8 were found in saliva from OLP patients.22-24 In those studies, IL-8 was detected at high concentration in erosive type OLP patients. Lu et al25 reported recently that the salivary levels of TNF-α, IL-1α, IL-6, and IL-8 in
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Figs 3a to 3c Correlation between saliva cytokine and NAS score change. Saliva was collected weekly for cytokine analysis. IL-1β (a) and IL-8 level (b) in saliva were detected by ELISA. Patients were grouped based on overall NAS score decrease by 3. Patients whose NAS score decreased more than 3 showed significantly higher level of IL-1β and IL-8. (c) Close correlation between IL-1β and IL-8 was detected.
OLP patients decreased significantly after treatment with dexamethasone, and visual analog scale value was significantly correlated with the decrease in IL-1α and IL-8. However, the relationship between inflammatory cytokines in saliva and symptom and signs of OLP is controversial. Several studies reported associations between inflammation and the levels of IL-1β in serum and synovial fluid of rheumatoid arthritis patients with temporomandibular joint disorders.26,27 Zhang et al22 note an association between IL-8 and clinical severity of OLP patients. They suggested that IL-8 is important in transformation of reticular to erosive form and could be a sensitive marker in monitoring disease activity. To determine the association between salivary cytokine and treatment responses, patients were grouped by NAS decrease. Topical tacrolimus is an effective treatment approach for OLP and overall treatment response revealed a visual analog scale decrease of around 3.28 Although direct comparison with the tacro-
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**
8
8
*
** 6 NAS score
6 NAS score
**
**
4
4
2
2
Pt 15
Pt 7 0
0 a
Before
4 wk
Follow up
b
Before
4 wk
Follow up
Figs 4a and 4b NAS score changes over time. NAS score was recorded before, after 4 week application, and at further following treatment with topical steroids. (a) Group 1 = NAS decreased more than 3, the solid line is patient 7 of Fig 2b. (b) Group 2 = NAS decreased less than 3, the solid line is patient 15 of Fig 2a (*P < .05, **P < .005).
limus study is not appropriate, we grouped patients based on an NAS score decrease of 3. Significantly higher salivary IL-1 and IL-8 level was detected in patients whose NAS decreased more than 3 compared to those that decreased less than 3. However, there was no significant association between the levels of IL-1β and IL-8 and severity or the type and the size of lesion. We also examined if the levels of IL-1β and IL-8 decrease after treatment with sulfasalazine. There was no statistically significant association between IL-1β and IL-8 and the response to sulfasalazine therapy. The small number of the patients enrolled in this study may be one of the reasons why there was no significant association. In addition, it was found that oral lesions in both groups were more susceptible to steroid treatment after topical sulfasalazine application over time compared to those without topical sulfasalazine treatment. To see the change over time, the patients were divided into two groups. Group 1 was assembled of patients whose NAS decreased more than 3, and the 15 patients who had an NAS decrease of less than 3 were in group 2. After 4 weeks of application of topical sulfasalazine and 4 weeks’ observation, there was little change in the severity of oral lesions. However, oral lesions in both groups, especially group 1, were more susceptible to steroid treatment after sulfasalazine application over time compared to before treatment with sulfasalazine
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(Fig 4; P value < .005). In the case of group 2, who showed a little response to topical sulfasalazine, the response to steroid therapy after sulfasalazine application was more improved in decreasing the sizes of lesions and NAS over time. These results show a possible treatment for refractory OLP by combining corticosteroids and topical sulfasalazine. Additional research on the effect of topical sulfasalazine with corticosteroid in OLP treatment is required. In this study, sulfasalazine was used for OLP treatment for the first time. The patients recruited for topical sulfasalazine application were mainly selected based on NAS. There is a high correlation between psychologic factors such as stress, depression, and anxiety and symptoms of OLP.29 Thus, having a NAS score of more than 4 could accelerate the progression of OLP by acting as factors that lower quality of life due to discomfort, which in turn worsen the symptoms of OLP. When OLP unresponsive to steroid therapy was treated with sulfasalazine topically, most of the lesions showed reduction in lesion size and NAS after the treatment. Interestingly, the lesions that did not respond to steroid treatment became more susceptible to steroid therapy with time. These results are inspiring and useful for the treatment of refractory OLP. As for the severity of OLP, there was no significant reduction in its severity. It was likely that the relatively small sample size might contribute to this result. The intervention and measure-
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ments were performed by a non-blinded researcher. However, potential bias was minimized by the random assignment of the participants and the use of a standardized protocol. In future studies, a randomized controlled trial with the control group including the steroid or sulfasalazine placebo will be needed. In conclusion, topical sulfasalazine should be considered for OLP treatment that does not respond to steroid treatment. Furthermore, a high concentration of IL-1β and IL-8 in the saliva could be an indicator for the application of topical sulfasalazine in OLP patients refractory to steroid treatments.
ACKNOWLEDGMENT This study was supported by Biomedical Research Institute Grant (2011-24), Pusan National University Hospital.
REFERENCES 1. Roopashree MR, Gondhalekar RV, Shashikanth MC, George J, Thippeswamy SH, Shukla A. Pathogenesis of oral lichen planus: a review. J Oral Pathol Med 2010;39:729–734. 2. Ismail SB, Kumar SK, Zain RB. Oral lichen planus and lichenoid reactions: Etiopathogenesis, diagnosis, management and malignant transformation. J Oral Sci 2007;49:89–106. 3. Eisen D. The clinical features, malignant potential, and systemic associations of oral lichen planus: A study of 723 patients. J Am Acad Dermatol 2002;46: 207–214. 4. Demitsu T, Sato T, Inoue T, Okada O, Kubota T. Corticosteroid-resistant erosive oral lichen planus successfully treated with topical cyclosporine therapy. Int J Dermatol 2000;39:79–80. 5. Edwards PC, Kelsch R. Oral lichen planus: Clinical presentation and management. J Can Dent Assoc 2002;68:494–499. 6. Farhi D, Dupin N. Pathophysiology, etiologic factors, and clinical management of oral lichen planus, part I: Facts and controversies. Clin Dermatol 2010;28: 100–108. 7. Thiele-Bruhn S, Beck IC. Effects of sulfonamide and tetracycline antibiotics on soil microbial activity and microbial biomass. Chemosphere 2005;59:457–465. 8. Marzano IM, Franco MS, Silva PP, et al. Crystal structure, antibacterial and cytotoxic activities of a new complex of bismuth(III) with sulfapyridine. Molecules 2013;18:1464–1476. 9. McGirt LY, Vasagar K, Gober LM, Saini SS, Beck LA. Successful treatment of recalcitrant chronic idiopathic urticaria with sulfasalazine. Arch Dermatol 2006;142:1337–1342. 10. el-Mofty M, el-Darouti M, Rasheed H, et al. Sulfasalazine and pentoxifylline in psoriasis: A possible safe alternative. J Dermatolog Treat 2011;22:31–37.
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11. Rashidi T, Mahd AA. Treatment of persistent alopecia areata with sulfasalazine. Int J Dermatol 2008;47:850–852. 12. Bauza A, Espana A, Gil P, Lloret P, Vazquez Doval FJ. Successful treatment of lichen planus with sulfasalazine in 20 patients. Int J Dermatol 2005;44: 158–162. 13. Omidian M, Ayoobi A, Mapar MA, Feily A, Cheraghian B. Efficacy of sulfasalazine in the treatment of generalized lichen planus: Randomized double-blinded clinical trial on 52 patients. J Eur Acad Dermatol Venereol 2010;24: 1051–1054. 14. Thongprasom K, Luangjarmekorn L, Sererat T, Taweesap W. Relative efficacy of fluocinolone acetonide compared with triamcinolone acetonide in treatment of oral lichen planus. J Oral Pathol Med 1992;21:456–458. 15. Sugerman PB, Savage NW, Walsh LJ, et al. The pathogenesis of oral lichen planus. Crit Rev Oral Biol Med 2002;13:350–365. 16. Thornhill MH. Immune mechanisms in oral lichen planus. Acta Odontol Scand 2001;59:174–177. 17. Baccaglini L, Thongprasom K, Carrozzo M, Bigby M. Urban legends series: Lichen planus. Oral Dis 2013;19:128–143. 18. Thongprasom K, Prapinjumrune C, Carrozzo M. Novel therapies for oral lichen planus. J Oral Pathol Med 2013;42:721–727. 19. Lee HJ, Zhang H, Orlovich DA, Fawcett JP. The influence of probiotic treatment on sulfasalazine metabolism in rat. Xenobiotica 2012;42:791–797. 20. Lawrence HP. Salivary markers of systemic disease: Noninvasive diagnosis of disease and monitoring of general health. J Can Dent Assoc 2002;68:170–174. 21. Cheng B, Rhodus NL, Williams B, Griffin RJ. Detection of apoptotic cells in whole saliva of patients with oral premalignant and malignant lesions: A preliminary study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;97: 465–470. 22. Zhang Y, Lin M, Zhang S, et al. NF-kappaB-dependent cytokines in saliva and serum from patients with oral lichen planus: A study in an ethnic Chinese population. Cytokine 2008;41:144–149. 23. Rhodus NL, Cheng B, Myers S, Miller L, Ho V, Ondrey F. The feasibility of monitoring NF-kappaB associated cytokines: TNF-alpha, IL-1alpha, IL-6, and IL-8 in whole saliva for the malignant transformation of oral lichen planus. Mol Carcinog 2005;44:77–82. 24. Yamamoto T, Osaki T, Yoneda K, Ueta E. Cytokine production by keratinocytes and mononuclear infiltrates in oral lichen planus. J Oral Pathol Med 1994;23: 309–315. 25. Lu R, Zhang J, Sun W, Du G, Zhou G. Inflammation-related cytokines in oral lichen planus: an overview. J Oral Pathol Med 2015;44:1–14. 26. Zhu X, Song Y, Huo R, et al. Cyr61 participates in the pathogenesis of rheumatoid arthritis by promoting proIL-1β production by fibroblast-like synoviocytes through an AKT-dependent NF-κB signaling pathway. Clin Immunol 2015;157:187–197. 27. Akutsu M, Ogura N, Ito K, Kawashima M, Kishida T, Kondoh T. Effects of interleukin-1β and tumor necrosis factor-α on macrophage inflammatory protein-3α production in synovial fibroblast-like cells from human temporomandibular joints. J Oral Pathol Med 2013;42:491–498. 28. Eckardt A, Völker B, Starke O, Kaever V, Kapp A. Topical tacrolimus in erosive oral lichen planus: An effective treatment approach. Oral Biosci Med 2005;4: 235–240. 29. Alshahrani S, Baccaglini L. Psychological screening test results for stress, depression, and anxiety are variably associated with clinical severity of recurrent aphthous stomatitis and oral lichen planus. J Evid Based Dent Pract 2014;14:206–208.
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ORAL MEDICINE
Sung-Hee Jeong
Topical sulfasalazine for unresponsive oral lichen planus Sung-Hee Jeong, DMD, MSD, PhD1/Hee-Sam Na, MD, MSD, PhD2/Su-Hyeon Park, DDS3/Yong-Woo Ahn, DDS, MSD, PhD 4/Jin Chung, DDS, MSD, PhD5 Objective: The purpose of this study was to evaluate the usefulness of topical sulfasalazine in the treatment of oral lichen planus (OLP) resistant to corticosteroid therapy. Method and Materials: Twenty-one unresponsive OLP patients were treated with topical sulfasalazine 3 times a day for 4 weeks. Each patient’s symptoms and lesion size were evaluated at the beginning of therapy, and then after 4 weeks to determine the efficacy of topical sulfasalazine. Inflammatory cytokines levels in saliva were measured by ELISA. Results: Seventeen patients
(81%) reported improvement of discomfort and 12 patients (57%) had lesions decrease in size over 50%. Patients who had higher levels of IL-1β and IL-8 were more responsive to topical sulfasalazine therapy. Conclusion: Topical sulfasalazine should be considered when OLP does not respond to corticosteroid therapy. Furthermore, high concentrations of IL-1β and IL-8 in the saliva are useful indicators for the application of topical sulfasalazine in OLP patients refractory to steroid treatment. (Quintessence Int 2016;47:319–327; doi: 10.3290/j.qi.a34974)
Key words: sulfasalazine, topical application, unresponsive oral lichen planus
Oral lichen planus (OLP) is a chronic inflammatory disease that affects the mucosal membrane. T-cell mediated damage against the mucosal epithelial cells is implicated in the pathogenesis of OLP,1,2 although the exact mechanism is unknown. Clinical forms of OLP include reticular, papular, plaque-like, erosive, atrophic, and bullous types of lesions.2 Patients who have erosive lesions usually com1
Associate Professor, Department of Oral Medicine, School of Dentistry, Pusan National University, Dental Research Institute, Yangsan, Republic of Korea.
2
Assistant Professor, Department of Oral Microbiology, School of Dentistry, Pusan National University, Yangsan, Republic of Korea.
3
Postgraduate Student, Department of Oral Medicine, School of Dentistry, Pusan National University, Dental Research Institute, Yangsan, Republic of Korea.
4
Professor, Department of Oral Medicine, School of Dentistry, Pusan National University, Dental Research Institute, Yangsan, Republic of Korea.
5
Professor, Department of Oral Microbiology, School of Dentistry, Pusan National University, Yangsan, Republic of Korea.
Correspondence: Dr Jin Chung, Department of Oral Microbiology, School of Dentistry, Pusan National University, Beomeo-ri, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, 626-770, Republic of Korea. Email: [email protected]
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plain more of soreness and difficulties with eating, drinking, tooth brushing, and speaking than other forms of OLP.3 Several immunosuppressants including corticosteroid, cyclosporine,4 and tacrolimus5 are widely used to reduce pain and inflammation in OLP patients. Topical applications are used primarily because they are easy to apply and have potent effects on local lesions. In the absence of response of topical medications, intralesional injection or systemic administration should be considered. Regardless of administration route, several side effects of these drugs have been reported, limiting their clinical use.6 Therefore, patients with refractory OLP need new treatments that are more effective but have fewer side effects. Sulfasalazine is extensively used in inflammatory bowel disease and is effective on immune-related inflammatory disease such as Crohn’s disease, rheumatoid arthritis, and Behcet’s disease. In spite of its effectiveness, the anti-inflammatory mechanism is not
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clearly understood. When orally administered, sulfasalazine is metabolized into 5-aminosalicylic acid (5-ASA) and sulfapyridine in the intestine. Sulfapyridine is known to have antimicrobial effects,7,8 whereas 5-ASA has anti-inflammatory actions.9 Sulfasalazine is effective for dermatologic diseases including psoriasis,10 alopecia areata,11 and even lichen planus (LP).12 Sulfasalazine has been suggested as a therapeutic option that has no major adverse effects in the treatment of LP.12,13 However, oral administration of sulfasalazine was not effective on mucosal LP and there has been no other attempt using topical application with this medicine. Thus, in the present study, we assessed the effect of topical application of sulfasalazine in patients with symptomatic OLP resistant to corticosteroid therapy.
METHOD AND MATERIALS Ethics This study was an open-trial investigation and was approved by the Pusan National University Hospital Ethics Committee (2010079). The protocol and consent forms were approved by the Ministry of Food and Drug Administration in Korea and registered to the Clinical Research Information service of Korea National Institute of Health (http://cris.nih.go.kr-KCT0000665).
Subjects Between 2010 and 2011, 210 patients were diagnosed with OLP based on clinical and histologic findings, and received treatment with corticosteroids at Pusan National University Dental Hospital, Republic of Korea. Steroid therapy was performed by topical application or oral administration. In most cases, initial steroid therapy was performed by topical dexamethasone (0.05%) in the form of a mouthwash. After that, prednisolone mouthwash (30 mg/500 mL), dexaltin ointment (0.1% dexamethasone), or triamcinolone acetonide ointment (0.1%) was used depending upon the severity of lesions. Prednisolone was administered orally when the lesions failed to improve after the initial treatments. Patients taking medication for or having a history of
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immune-related diseases like atopic eruption, rheumatoid arthritis, skin lichen planus, or colitis were excluded. For this study, we selected patients whose symptoms appeared to be over a numerical analog scale (NAS, range 0–10) of 4 regardless of the lesion type, although the conditions alternated between improving and worsening repeatedly. Twenty-one patients among those selected were finally recruited into this study (Table 1). All the patients agreed to this trial and were given a full description about sulfasalazine and its procedure. All patients provided informed written consent. The patients were asked to maintain proper plaque control with commercially available dentifrice without sodium lauryl sulfate (SLS-free dentifrice), and they had a wash-out period of 2 weeks. The treatment solution contained 30 mg of sulfasalazine (Hanlim Pharm) in 5 mL of distilled water and was applied three times a day for 3 to 5 minutes and then expectorated. The patients were requested not to eat or drink for 30 minutes afterwards and were restricted from using any other medication. The primary outcome measure was based on the disease severity and the sizes of the lesions which were also measured in the patients with secondary outcomes of symptom changes. The severity of lesions were recorded following the criteria scale by Thongprasom et al14 as follows: • 0 = no lesion/normal mucosa • 1 = mild white striae/no erythematous area • 2 = white striae with atrophic area 1 cm2 • 4 = white striae with erosive area 1 cm2. The patients were grouped based on three levels: mild (0,1), moderate (2,3), and severe (4,5). To evaluate the changes of symptoms, patients were asked to use a NAS, and the lesions were recorded using a transparent grid divided into calibrated 2 mm2 that was placed over the lesion and traced. We measured the lesion size within the boundary of the whole lesion which included the white striae, erythema, and erosion.
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Table 1
Clinical information of OLP patients before topical sulfasalazine application
Patient
Sex/ age
Time of illness (days) at first visit
Location of lesions
Type of OLP
1
F/45
2
F/50
120
B,V
R,A
120
G,B,V
R,A
3
M/39
50
4
F/38
150
B,V
R,A,E
B
R,A
5
F/42
6
F/56
365
B,V
R,A
395
G,B,V
R,A,E
7 8
F/61
60
G,B,V
R,A,E
F/54
120
B
R,A,E
9
F/48
90
B,V
R,A
10
F/45
365
B,V
11
F/43
180
G,B,V
12
F/36
30
13
F/50
120
14
M/49
15
F/47
730
16
F/39
30
17
F/49
18
M/40
19
F/56
20
F/40
30
21
F/58
150
Duration of steroid therapy (days)
NAS*
Severity of lesions
Size of lesions (mm2)
228
5
Moderate
164
225
5
Mild
312
48
5
Moderate
336
3,440
5
Mild
100
64
5
Mild
508
273
5
Severe
240
239
4
Severe
288
760
5
Severe
336
116
5
Mild
264
R,A
49
5
Mild
102
R,A
293
4
Mild
132
G,B,V
R,A
90
5
Moderate
320
B
R,A
69
6
Mild
160
B,T
R,A,E
72
7.5
Severe
316
G
R,A
160
4
Mild
92
B,V
R,A
237
5
Mild
52
150
G,V
R,A
293
5
Mild
84
120
B,V
R,A
141
6
Mild
180
120
G,B,V
R,A
768
5
Mild
769
G,B,V,T
R,A
47
5
Mild
64
G,V
R,A
481
6
Mild
78
3,650
A, atropic form; B, buccal mucosa; E, erosive form; G, gingiva; R, reticular form; T, tongue; V, vestibule. *NAS, numerical analog scale (range 0–10) at the first day application.
This evaluation was recorded weekly before and after using topical sulfasalazine. All the patients were treated for 4 weeks and further followed for 4 weeks after finishing the application. After these experiments, the severity of lesions and NAS were recorded whenever they visited the clinic. Thirty healthy volunteers took the same topical sulfasalazine as a control. We recorded statements about taste, flavor, sensation, and any influence on oral mucosa. There are two controls within this experimental protocol: first the patients themselves who were on steroid prior to the sulfasalazine, and second the healthy volunteers on sulfasalazine. The healthy volunteers served as a control for side effects and cytotoxic effects. The patients who were on steroids before served as a paired control for comparison of treatment.
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Collection of saliva and cytokine ELISA The whole unstimulated saliva (WUS) of the experimental patients and healthy volunteers was collected at every visit between 9:00 and 11:00 a.m. The subjects refrained from eating and drinking for 1 hour prior to the collection. All subjects were asked to tilt their head forward, and then drooled WUS into a sterile tube without swallowing for 5 minutes. All the samples were immediately frozen at −80°C until usage. The protein levels of interleukin 1β (IL-1β) and IL-8 in the saliva were analyzed by using an ELISA kit from eBioscience. Standard or saliva was added to an ELISA well plate pre-coated with specific monoclonal capture antibody. After incubating for 2 hours at room temperature, anti-IL-1β and anti-IL-8 antibody conjugated with biotin was added. After incubation for 1 hour at
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Lesion decrease (%)
100 80 60 40 20 0
0
1 2 NAS change
>3
Fig 1 Correlation between lesion size % change and NAS score change during topical sulfasalazine treatment. NAS scores and lesion size were measured weekly before and during treatment.
room temperature, streptavidin conjugated with horseradish peroxidase was added to the solution. Substrate solution containing chromogen was added and allowed to react for 30 minutes. The levels of cytokines were assessed by a microelisa reader at 450 nm.
Statistical analysis Data were analyzed using Prism GraphPad v5 (GraphPad Software). The Mann-Whitney U test was used to compare nonparametric unpaired data. The null hypotheses of no difference were rejected if P values were less than .05.
RESULTS Clinical results The sulfasalazine mouthwash had an astringent taste without any flavor, and had shown no specific sensation at the oral mucosa as reported by normal healthy volunteers. It had no influence on the oral mucosa of healthy participants during the 4 weeks of application. However, sulfasalazine mouthwash showed yellow stains on the tongue due to the color of the suspension, but this disappeared over time. Twenty-one patients with OLP resistant to steroid therapy were recruited and treated with topical sulfasalazine for 4 weeks. Study subject information is described in Table 1. OLP patients included three males
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and eighteen females aged between 36 and 61 years (mean age 46.9 years). Duration of illness by records at first visit ranged from 30 days to 10 years (mean time 11.3 months) and NAS was recorded at 4 to 7.5 at the beginning of sulfasalazine treatment. The lesion locations were anywhere on the oral mucosa including buccal mucosa, vestibule, tongue, or gingiva. The included lesions were symptomatic reticular, atropic, erosive/ulcerative, or mixed form of OLP and severity of lesions ranged from mild to severe (Table 1). Most patients with clinical symptom improvements reported early resolution of discomfort within 2 weeks after topical application of sulfasalazine. As shown in Fig 1, 17 patients (81%) displayed improved NAS changes ranged from 1 to 5. Twelve patients (57%) had lesions decrease in size over 50%. Eleven patients (52%) had lesions diminish over 50% and NAS decrease simultaneously (Fig 1). Figure 2 shows representative images of improved patients. The first case was the 15th patient, who had been treated with steroid therapy for 5 months without any improvement. After 4 weeks of topical sulfasalazine application, the white striae and atropic lesion on the maxillary right gingiva diminished and discomfort decreased (Fig 2a). At the last visit after 16 weeks, the patient reported that the NAS score went down to zero (see Fig 4b). In Case 7, the patient had been treated with steroid for 8 months without any improvement. After 4 weeks of topical sulfasalazine application, the size of the lesion on the right buccal mucosa diminished and discomfort decreased at 4 weeks without any additional application (Fig 2b). At the last visit after 3 weeks, the patient reported that the NAS score went down to 0.5 (see Fig 4a).
Cytokines in saliva To determine factors more favorable for sulfasalazine treatment, information including sex, age, type of OLP, time of illness, duration of steroid therapy, and pro-inflammatory cytokines in saliva was analyzed. Sex, age, type of OLP, time of illness, and duration of steroid therapy were not associated with NAS or lesion size
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a
c
b
d
e
Figs 2a to 2e Representative images of improved patients. (a and b) Clinical photos of case 15. This patient was treated with steroid for 5 months. (a) Maxillary right gingiva before treatment with sulfasalazine; (b) after 4 weeks application of topical sulfasalazine. (c and d) Clinical photos of case 7. This patient was treated with steroid for 8 months. (c) Right buccal mucosa before treatment with sulfasalazine, (d) after 4 weeks application of topical sulfasalazine, and (e) 2 weeks after final treatment.
change (Table 2). Among various pro-inflammatory cytokines, IL-1β and IL-8 were significantly increased in OLP patients compared to healthy subjects in the preliminary study (results not shown). There was also a positive correlation between NAS change and pro-inflammatory cytokine level. Patients whose NAS improved by more than 3 (group 1) showed significantly higher salivary IL-1β and IL-8 levels than those whose NAS improved less than 3 (group 2) (Table 2 and Fig 3). Moreover, as shown in Fig 3c, salivary IL-1β and IL-8 are closely correlated (r = 0.8713). However, when cytokine levels in saliva were analyzed throughout the treatment, no significant change was observed (results
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not shown). There was no correlation between pro-inflammatory cytokine level and lesion size or lesion size change percent (results not shown).
DISCUSSION OLP is a chronic inflammatory disease and the exact pathologic process is unknown, although research indicates that OLP is a T-cell mediated autoimmune disease.15-17 Steroids are considered the first-line treatment for OLP, especially as topical application. Other topical agents such as tacrolimus, pimecrolimus, cyclosporine, and aloe vera have been tried.18 However, these had a
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Table 2
Summary of OLP patients treated with topical sulfasalazine grouped by NAS* change
Sex Age (y)
Group 1†
Group 2‡
5F, 1M
11F, 2M
49.0 ± 10.4
Time of illness (mo)
P value
49.1 ± 11.3
.8761
2.5 ± 1.5
15.3 ± 29.6
.3110
318.8 ± 263.3
418.5 ± 854.3
.7849
Before
5.3 ± 0.5
5.3 ± 0.9
.8268
After
1.5 ± 1.0
4.4 ± 0.9
.0006**
257.5 ± 264.1
268.5 ± 159.3
.4594
81.3 ± 85.2
140.6 ± 103.6
.1727
65.5 ± 23.8
50.1 ± 13.7
.1098
IL-1β (pg/mL)
336.0 ± 201.3
154.0 ± 68.9
.0216**
IL-8 (pg/mL)
419.1 ± 173.1
230.6 ± 141.0
.0176**
Duration of steroid therapy (d) NAS Before Size of lesion (mm2) After Size decrease %
*NAS, numerical analog scale, range 0–10. **P < 0.05. †Group 1: NAS decreased more than 3 (n = 6). ‡Group 2: NAS decreased less than 3 (n = 15).
similar or less effect than corticosteroids. When OLP patients do not respond to steroid therapy, few substitutes offer cure. Sulfasalazine is used for ulcerative colitis, Crohn’s disease, and is a second-line drug for rheumatoid arthritis. Sulfasalazine is also suggested as a therapeutic option in the treatment of LP without major adverse effects.12,13 However, oral application of sulfasalazine was not effective on mucosal LP. When orally administered, sulfasalazine is metabolized into 5-ASA and sulfapyridine by azoreductase of gut microbiota. Among various bacteria, Lactobacillus acidophilus, Bifidobacterium lactis, and Streptococcus salivarius possess azoreductase activity.19 In the oral cavity, Streptococcus species including S salivarius comprise the majority of oral microbiota. Therefore, it was hypothesized that drug directly applied to the oral mucosa could be effective in treating refractory OLP. To titrate the dosage of topical sulfasalazine, trials were performed with three different dosages: 500 mg/5 mL, 200 mg/5 mL, 30 mg/5 mL. Healthy subjects did not report any discomfort or mucosal changes. However, OLP patients felt a burning sensation to topical sulfasalazine in the 500 mg/5 mL and 200 mg/5 mL solutions, but not the 30 mg/5 mL dose. Therefore, we selected the
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30 mg/5 mL for application dosage and expected to get no systemic effects after swallowing as the dosages were nowhere close to those used for other diseases. The patients enrolled in this study were previously treated with steroids without satisfactory results. Some patients with steroid therapy showed improvement, while others did not feel any improvement. Therefore, we chose patients treated with steroids whose NAS did not decrease below 4. Among them, we selected volunteers for the study, and 21 patients were selected for topical application of sulfasalazine. The type of lesions was not considered. Most of the patients tolerated the treatment of topical sulfasalazine well. Some patients complained of some discomfort such as a mild burning sensation at the first week and yellow discoloration on oral mucosa that disappeared after treatment. There were no major side effects such as systemic influence and cutaneous changes. After the application of topical sulfasalazine, patients reported the improvement of the feeling of constriction during mouth opening and hypersensitivity to hot or spicy food. Seventeen patients (81%) displayed improved NAS changes and twelve patients (57%) had lesions decrease in size over 50%. Omidian et al13 found systemic administration of maximum 2.5 g/
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800
800 P = 0.010
600
IL-8 (pg/ml)
IL-1β (pg/ml)
P = 0.0038
400
200
600
400
200
0
Group 1
0
Group 2
a
Group 1
Group 2
b
IL-8 (pg/ml)
800 600 r2 = 0.7591
400 200 0 0
c
200
400 IL-1β (pg/ml)
600
800
day sulfasalazine effective on pruritic lesions, but ineffective on mucosal lesions. As shown in the results of the present study, a little amount of topical application of sulfasalazine on oral mucosal lesions could be more effective than oral administration. Oral fluid analysis could be used in the monitoring of diseases, and the results correlate with those from blood.20 The initiation and progression of oral disease are mediated by inflammatory response, and cytokines are well known inflammatory mediators. Pro-inflammatory cytokines have been detected in oral fluid of the patients with Sjögren’s syndrome, OLP, oral leukoplakia, and oral squamous carcinoma.21 High concentrations of nuclear factor κB (NF-κB)-dependent cytokines including tumor necrosis factor α (TNF-α), IL-1α, IL-6, and IL-8 were found in saliva from OLP patients.22-24 In those studies, IL-8 was detected at high concentration in erosive type OLP patients. Lu et al25 reported recently that the salivary levels of TNF-α, IL-1α, IL-6, and IL-8 in
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Figs 3a to 3c Correlation between saliva cytokine and NAS score change. Saliva was collected weekly for cytokine analysis. IL-1β (a) and IL-8 level (b) in saliva were detected by ELISA. Patients were grouped based on overall NAS score decrease by 3. Patients whose NAS score decreased more than 3 showed significantly higher level of IL-1β and IL-8. (c) Close correlation between IL-1β and IL-8 was detected.
OLP patients decreased significantly after treatment with dexamethasone, and visual analog scale value was significantly correlated with the decrease in IL-1α and IL-8. However, the relationship between inflammatory cytokines in saliva and symptom and signs of OLP is controversial. Several studies reported associations between inflammation and the levels of IL-1β in serum and synovial fluid of rheumatoid arthritis patients with temporomandibular joint disorders.26,27 Zhang et al22 note an association between IL-8 and clinical severity of OLP patients. They suggested that IL-8 is important in transformation of reticular to erosive form and could be a sensitive marker in monitoring disease activity. To determine the association between salivary cytokine and treatment responses, patients were grouped by NAS decrease. Topical tacrolimus is an effective treatment approach for OLP and overall treatment response revealed a visual analog scale decrease of around 3.28 Although direct comparison with the tacro-
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**
8
8
*
** 6 NAS score
6 NAS score
**
**
4
4
2
2
Pt 15
Pt 7 0
0 a
Before
4 wk
Follow up
b
Before
4 wk
Follow up
Figs 4a and 4b NAS score changes over time. NAS score was recorded before, after 4 week application, and at further following treatment with topical steroids. (a) Group 1 = NAS decreased more than 3, the solid line is patient 7 of Fig 2b. (b) Group 2 = NAS decreased less than 3, the solid line is patient 15 of Fig 2a (*P < .05, **P < .005).
limus study is not appropriate, we grouped patients based on an NAS score decrease of 3. Significantly higher salivary IL-1 and IL-8 level was detected in patients whose NAS decreased more than 3 compared to those that decreased less than 3. However, there was no significant association between the levels of IL-1β and IL-8 and severity or the type and the size of lesion. We also examined if the levels of IL-1β and IL-8 decrease after treatment with sulfasalazine. There was no statistically significant association between IL-1β and IL-8 and the response to sulfasalazine therapy. The small number of the patients enrolled in this study may be one of the reasons why there was no significant association. In addition, it was found that oral lesions in both groups were more susceptible to steroid treatment after topical sulfasalazine application over time compared to those without topical sulfasalazine treatment. To see the change over time, the patients were divided into two groups. Group 1 was assembled of patients whose NAS decreased more than 3, and the 15 patients who had an NAS decrease of less than 3 were in group 2. After 4 weeks of application of topical sulfasalazine and 4 weeks’ observation, there was little change in the severity of oral lesions. However, oral lesions in both groups, especially group 1, were more susceptible to steroid treatment after sulfasalazine application over time compared to before treatment with sulfasalazine
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(Fig 4; P value < .005). In the case of group 2, who showed a little response to topical sulfasalazine, the response to steroid therapy after sulfasalazine application was more improved in decreasing the sizes of lesions and NAS over time. These results show a possible treatment for refractory OLP by combining corticosteroids and topical sulfasalazine. Additional research on the effect of topical sulfasalazine with corticosteroid in OLP treatment is required. In this study, sulfasalazine was used for OLP treatment for the first time. The patients recruited for topical sulfasalazine application were mainly selected based on NAS. There is a high correlation between psychologic factors such as stress, depression, and anxiety and symptoms of OLP.29 Thus, having a NAS score of more than 4 could accelerate the progression of OLP by acting as factors that lower quality of life due to discomfort, which in turn worsen the symptoms of OLP. When OLP unresponsive to steroid therapy was treated with sulfasalazine topically, most of the lesions showed reduction in lesion size and NAS after the treatment. Interestingly, the lesions that did not respond to steroid treatment became more susceptible to steroid therapy with time. These results are inspiring and useful for the treatment of refractory OLP. As for the severity of OLP, there was no significant reduction in its severity. It was likely that the relatively small sample size might contribute to this result. The intervention and measure-
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Q U I N T E S S E N C E I N T E R N AT I O N A L Jeong et al
ments were performed by a non-blinded researcher. However, potential bias was minimized by the random assignment of the participants and the use of a standardized protocol. In future studies, a randomized controlled trial with the control group including the steroid or sulfasalazine placebo will be needed. In conclusion, topical sulfasalazine should be considered for OLP treatment that does not respond to steroid treatment. Furthermore, a high concentration of IL-1β and IL-8 in the saliva could be an indicator for the application of topical sulfasalazine in OLP patients refractory to steroid treatments.
ACKNOWLEDGMENT This study was supported by Biomedical Research Institute Grant (2011-24), Pusan National University Hospital.
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