Methotrexate Supplemented with Steroid Ointments for the Treatment of Severe Erosive Lichen Ruber

Sir, and pain; endometriosis was also diagnosed and treated. At Ž rst, the erosive lichen was treated with steroid Erosive lichen ruber is a disease with severe symptoms (1, 2) which aVect the quality of life of patients in many ointments. She was also given cyclosporin, which brought about some improvement but had to be withways. The main symptoms consist of pain, bleeding and a feeling of rawness caused by desquamation of the drawn because of side eVects. Treatment with methotrexate (10 mg/week) was inisurface epithelium and adhesions caused by healing with scar formation causing even more symptoms. The syntiated, with the patient gradually improving; after 9 months the dose was increased to 15mg/week, with drome often similarly aVects the mouth and the genital area (2, 3), but it may also cause changes in several further improvement of the symptoms. After 13 months she was given oral steroids, as supplement, for a short other organs (4, 5). Although the aetiology is unknown, it is thought to be associated with autoimmune diseases period. At follow-up, 17 months after starting treatment with methotrexate, her oral mucosa was almost com(6, 7). As the disease aVects both the oral and the genital area, physicians and dentists have to collaborate pletely healed and in the vulva and the vagina there was only a small, eroded area. Methotrexate was stopped 2 closely. Treatment of erosive lichen ruber is diYcult and complicated and there is no treatment available that months afterwards. One year later the patient contracted symptoms of colitis and a year and a half later she cures the disease once and for all (6, 7). There are no large randomized clinical trials concerning treatment of gradually got symptoms from erosive lichen ruber, although less severely than previously. this disease (8), and no controlled studies evaluating the eYcacy of oral corticosteroids in mucous lichen (8). It is stated that there is no accessible treatment superior Patient 2 to steroid ointments in oral lichen (8), and corticosteroids locally and/or orally are the most frequently This 60-year-old woman with a disease history of more used treatment (2, 9, 10). Supplementary treatment is than 10 years and many diVerent treatments had been necessary for patients with erosive lichen with insuYcient tested before referral. Her symptoms were mainly loceVect of treatment and persisting severe symptoms and ated to the vulva and the mouth, where the ulcers caused signs. Our data show that oral methotrexate in a dosage burning at urination and made eating diYcult. Initially, of 10–15mg/week is a well-tolerated and successful she was given steroid ointments and oral steroids comtreatment in patients severely aVected by erosive lichen bined with azathioprine. The symptoms from the mouth ruber. and oesophagus became worse, making eating very diYcult. After treatment for oral candidosis her eating problem vanished. Methotrexate started at a dosage of CASE REPORTS 10mg/week, plus local steroid ointments, was increased after 7 months to 15 mg/week, but was stopped after 17 We describe 4 patients (3 women and 1 man) with clinical signs of erosive lichen ruber. They were all months when the patient was free of symptoms in the vulva but still had some mild, oral symptoms. After 4 diagnosed after referral to us, and the diagnosis was veriŽ ed by biopsies. They all had complicated symptoms years, her symptoms and signs are still in a fairly stable phase, requiring only local steroid ointments. that severely aVected their daily lives, e.g. they were not able to eat and drink what they wished, the women were unable to have intercourse and they suVered pain when Patient 3 urinating. Treatment was initiated with steroid ointments in all patients. A 45-year-old woman with more than 10 years of symptoms in the mouth and genital area. Initially, she was treated with oral steroids combined with azathioPatient 1 prine and, later, steroid ointments. Methotrexate was started at a dosage of 10mg/week and improvement This 30-year-old woman had a history of erosive lichen ruber lasting about 10 years. Her symptoms were localwas seen after 2 months. After 6 months she had very few symptoms from the genitalia but some from the ized to the oral cavity, vulva and vagina. After some years she gradually developed colitis, causing bleeding oral cavity. After 21 months, treatment was stopped,