A 52-year-old woman presents with a 3-month history of painful erosions on the buccal mucosa and gingiva, along with a reticular pattern of white lines. Oral examination reveals Wickham's striae and erosive lesions. A biopsy confirms lichen planus. She reports difficulty eating and speaking. What is the most appropriate next step in management?

Explanation

## Management of Erosive Oral Lichen Planus **Key Point:** Erosive oral lichen planus requires topical corticosteroids as first-line therapy, applied directly to the affected mucosa to minimize systemic absorption and side effects. ### Rationale for Topical Corticosteroids **High-Yield:** Triamcinolone 0.1% paste or fluocinonide gel applied three times daily to erosions is the standard initial approach for symptomatic oral LP because: - Direct local anti-inflammatory effect on erosive lesions - Minimal systemic absorption when applied to oral mucosa - Reduces pain and promotes healing - Safe for prolonged use in oral cavity ### When to Escalate Therapy | Scenario | Next Step | |----------|----------| | Inadequate response to topical steroids after 4-6 weeks | Intralesional corticosteroid injections or systemic therapy | | Severe, widespread erosive disease affecting nutrition | Systemic corticosteroids (short course) | | Refractory cases | Topical calcineurin inhibitors (tacrolimus) or retinoids | **Clinical Pearl:** Erosive oral lichen planus is painful and can significantly impair oral function; topical therapy provides rapid symptom relief while avoiding systemic steroid side effects in the initial phase. **Warning:** Do not start systemic corticosteroids as first-line for localized erosive disease—reserve for extensive, refractory cases. Malignant transformation risk (0.5–5% over 5–10 years) warrants clinical surveillance, but oncology referral is premature without evidence of dysplasia or malignancy. [cite:Dermatology by Bolognia 4e Ch 15]