Oral lichen planus is a long-term inflammatory condition of the lining of the mouth, in which the immune system's T cells attack the cells lining the cheeks, tongue, or gums (StatPearls). It most often appears as white, lacy patches on the inside of the cheeks or on the tongue, and some people also have red, thin, or open areas that burn or sting, especially with spicy or acidic food (British Association of Dermatologists; StatPearls). It is not an infection and cannot be passed from one person to another (BISOM). A 2020 review of studies from around the world estimated that it affects a little under 1 in 100 people, and more often women and people aged 40 or older (Li et al. 2020).
In most people oral lichen planus cannot be cured, but it goes through quieter periods and flares, and treatment aims to ease soreness and settle flares (British Association of Dermatologists; StatPearls). Topical corticosteroids used inside the mouth, as an adhesive gel or paste or as a mouth rinse, are the usual first treatment (StatPearls). Few manufactured products are made for use in the mouth, so most of the preparations used in clinical trials were compounded (Cochrane review 2020). Bayview Pharmacy compounds steroid mouth rinses and pastes and a tacrolimus mouth rinse on prescription. Your dentist, oral medicine specialist, or dermatologist decides whether any of them fits your situation, and a valid prescription is required.
What does oral lichen planus look like?
Doctors describe several forms, including reticular, plaque, atrophic, erosive, and bullous (StatPearls). The reticular form, fine white lacy lines, is the classic pattern (StatPearls). Atrophic and erosive forms are red, thinned, or open areas that tend to hurt, and sensitivity to spicy or acidic food is a common complaint (StatPearls). When it affects the gums, they can look red and shiny, which is called desquamative gingivitis (British Association of Dermatologists).
Other conditions can look the same, including reactions to some medicines and to dental fillings, called oral lichenoid reactions (StatPearls). That is one reason a dentist or specialist examines the mouth and may take a small sample (biopsy), particularly when the white lacy pattern is missing (French guidelines 2022).
How is oral lichen planus treated?
Topical corticosteroids are the first-line treatment (StatPearls; Cochrane review 2020). They are applied as an adhesive gel or paste to a sore spot, or used as a mouth rinse that reaches widespread or hard-to-reach areas (StatPearls). A 2020 Cochrane review of 35 trials found low-certainty evidence, from 2 small trials of steroid gels, that a steroid may relieve pain better than a placebo. It found no consistent evidence that any one steroid works better than another (Cochrane review 2020; Cochrane review 2020).
Tacrolimus, which is not a steroid, is generally a second-line option (American Family Physician 2011). Very low-certainty evidence in the same review suggests it may resolve pain more often than clobetasol, in trials that used tacrolimus ointment, with conflicting results on how the patches look (Cochrane review 2020). Long, continuous courses of steroid treatment are not recommended because of side effects (Rotaru et al. 2020), so your prescriber sets how long and how often you use each preparation.
Mouth rinse or adhesive paste?
| Mouth rinse | Adhesive paste or gel | |
|---|---|---|
| What it is | A liquid you swish around the mouth and spit out | A thick paste or gel pressed onto a spot inside the mouth |
| Where it is often used | Widespread patches, or areas a paste cannot reach | One sore spot, or a few |
| Medicines Bayview prepares | Clobetasol, fluocinonide, triamcinolone, betamethasone, dexamethasone, tacrolimus | Clobetasol, clobetasol with lidocaine, fluocinonide, triamcinolone |
This comparison is for education only and is not a statement that either form is better or more effective. Your prescriber chooses the medicine, form, strength, and schedule.
Which medicines are used in the mouth?
Clobetasol propionate is a super-high-potency steroid (clobetasol topical label). In a small trial, 0.025% and 0.05% clobetasol in an adhesive gel gave similar results (Carbone et al. 2009). That trial tested a gel, not a rinse. Bayview prepares a 0.05% dental paste, a 0.05% oral gel with lidocaine 1%, a numbing medicine, and 0.025% and 0.05% mouth rinses. See clobetasol.
Fluocinonide. In a 2024 randomized trial of 47 people, a fluocinonide 0.05% gel was compared with a placebo, with results measured over 6 months of follow-up (Polizzi et al. 2024). Bayview prepares a 0.05% oral adhesive paste and a 0.05% mouth rinse. See fluocinonide.
Triamcinolone acetonide. A manufactured triamcinolone 0.1% dental paste is FDA-approved for the temporary relief of symptoms of oral inflammatory lesions (triamcinolone dental paste label), and Bayview dispenses it when it fits the prescription. Bayview compounds triamcinolone mouth rinses in 0.1%, 0.2%, and 0.4% strengths, the 0.4% without preservatives. See triamcinolone.
Dexamethasone mouth rinse. Dexamethasone rinses are often used when patches are widespread or hard to reach (StatPearls). A manufactured dexamethasone oral solution, 0.5 mg in 5 mL, is FDA-approved for conditions treated with the swallowed medicine, and its ingredient list does not include alcohol (dexamethasone oral solution label); the elixir version contains 5% alcohol (dexamethasone elixir label). Prescribers also use the solution off-label as a swish-and-spit rinse, and a small trial used dexamethasone 0.1 mg/mL solution alone as its comparison (Villa et al. 2020). When the manufactured solution fits the prescription, that is what Bayview dispenses. Bayview compounds a dexamethasone rinse in another strength, or in a mucoadhesive base (a thicker base designed to stick to the lining of the mouth), when your prescriber orders it.
Betamethasone tablets dissolved in water are used as a steroid mouthwash in UK practice, off-label (BISOM betamethasone mouthwash leaflet). Bayview is not aware of a betamethasone product made for the mouth that is sold in the United States, and compounds a betamethasone mouth rinse on prescription.
Tacrolimus calms the immune response in a different way from a steroid. In a trial comparing tacrolimus ointment with clobetasol ointment, 9 of the 16 people using tacrolimus said their burning got worse in the first 2 days, and it settled within 4 to 5 days (Corrocher et al. 2008). A review of 57 people using a 0.03% tacrolimus mouth rinse reported results up to 2 years after starting treatment; 4 of them (7%) developed mouth cancer during the observation period, and the study did not attribute this to tacrolimus (Utz et al. 2022). The manufactured tacrolimus ointment for the skin is labeled not for oral use, and its label says oral application is not recommended. It carries a boxed warning that long-term safety has not been established and that rare cases of skin cancer and lymphoma have been reported, although a causal link has not been shown (tacrolimus ointment label). Bayview compounds 0.03% and 0.1% tacrolimus mouth rinses. See tacrolimus.
How do I use a mouth rinse or paste?
Follow the directions on your label. For a rinse, measure the amount on the label, swish it around your mouth for the time directed, often 3 to 5 minutes, then spit it out and do not swallow it (BISOM betamethasone mouthwash leaflet). Try not to eat or drink for 30 minutes afterward so the medicine stays in contact with the patches (BISOM betamethasone mouthwash leaflet). Medicines prescribed as a mouthwash have been swallowed by mistake, so read the label each time (UHB Dental Hospital guide).
For a paste or gel, dry the area first and avoid eating or drinking for at least 30 minutes after applying it (StatPearls). Press a small dab onto the spot until a thin film forms, and do not rub it in (triamcinolone dental paste label).
Side effects & safety
Thrush. Thrush, a yeast infection that can cause white or red patches and soreness, is one of the most common side effects of steroids used in the mouth (StatPearls). In a review of 315 people treated with steroids for oral lichen planus, 13.6% developed a fungal infection (Marable et al. 2016). Your prescriber may add an antifungal if it happens (BISOM).
Absorption into the body. Some of a steroid used in the mouth is absorbed into the bloodstream (Varoni et al. 2012). Rarely, long daily use has led to Cushing syndrome and a period when the body made too little of its own cortisol; one published case followed about a year of daily use of a compounded mouthwash containing clobetasol, clotrimazole, and lidocaine (Lin et al. 2024). Use these preparations only as prescribed and for the length of time your prescriber sets.
Pregnancy and breastfeeding. Tell your prescriber if you are pregnant, planning a pregnancy, or breastfeeding. The label for the triamcinolone dental paste advises using it in pregnancy only if the potential benefit justifies the potential risk, and caution while nursing (triamcinolone dental paste label).
Living with oral lichen planus
Avoid spicy, salty, or acidic foods that cause soreness and mouthwashes that contain alcohol, and keep your mouth clean with a soft toothbrush (BISOM). A toothpaste without the foaming agent sodium lauryl sulfate may be more comfortable, and stopping smoking and cutting down on alcohol are advised (British Association of Dermatologists). Ask your dentist about sharp teeth or rough fillings that rub (StatPearls).
Oral lichen planus carries a small long-term risk of mouth cancer, around 1% over 10 years (BISOM; British Association of Dermatologists). Large reviews found that between about 0.4% and 1.4% of people with oral lichen planus in the included studies developed mouth cancer, with a higher risk in people who smoke or drink alcohol (Idrees et al. 2021; González-Moles and Ramos-García 2024). Regular check-ups with someone who knows the condition, at least once a year, help catch changes early (French guidelines 2022; BISOM).
Who should not use these preparations?
Do not use a preparation if you are allergic to its medicine or any other ingredient in it. The triamcinolone dental paste label says not to use it when there is a fungal, viral, or bacterial infection of the mouth or throat (triamcinolone dental paste label), so tell your prescriber about any mouth infection. Tell your prescriber about any other steroid you use, any medicine that weakens the immune system, and whether you are pregnant or breastfeeding.
How do I get started?
Talk with the dentist, oral medicine specialist, or dermatologist who manages your mouth. A licensed prescriber decides whether a rinse or paste is appropriate and chooses the medicine, strength, and schedule. Bayview Pharmacy does not provide consultations or determine appropriateness. Already have a prescription at another pharmacy? You can transfer it to Bayview. Once you have a prescription, your prescriber can order through Bayview, and a pharmacist is available if you have questions. These preparations are part of our compounded medications catalog, alongside magic mouthwash for other mouth sores.
Clinical details for prescribers
Regulatory. No product is FDA-approved specifically for oral lichen planus (Brennan et al. 2022). Two manufactured products can be used in the mouth and are dispensed as such when they fit: triamcinolone acetonide 0.1% dental paste (generics marketed; indicated for adjunctive treatment and temporary relief of symptoms of oral inflammatory and traumatic ulcerative lesions) (label), and dexamethasone oral solution 0.5 mg/5 mL (systemic indications; the Hikma solution lists no alcohol, the elixir contains 5%) (solution label; dexamethasone elixir label). Under FDA's 503A guidance, a compounded drug is essentially a copy of a commercially available product when it has the same active ingredient, the same, similar (within 10%), or easily substitutable strength (one reachable with fractional or multiple doses), and the commercial product can be used by the prescribed route (FDA guidance). A compounded dexamethasone 0.1 mg/mL rinse or triamcinolone 0.1% oral paste therefore needs the prescriber's determination of the significant difference it makes for the patient, which the guidance says should be documented on the prescription. No clobetasol, fluocinonide, betamethasone, or tacrolimus product is approved for use in the mouth; the clobetasol topical label reads not for oral use, and the tacrolimus ointment label says oral application is not recommended and carries the topical calcineurin inhibitor boxed warning (clobetasol label; tacrolimus ointment label).
Published evidence:
- Corticosteroids: Lodi et al. 2020 (Cochrane, 35 RCTs, 1,474 participants): steroid vs placebo for pain RR 1.91 (95% CI 1.08 to 3.36; 2 trials, 72 participants; low certainty); clinical response inconclusive; no steroid consistently superior to another; most trials used galenical preparations (Cochrane summary; Cochrane review 2020). Zheng et al. 2024: 17 RCTs of topical clobetasol, no GRADE rating, high or unclear risk of bias in most (Front Med).
- Clobetasol: Carbone et al. 1999, n=60, clobetasol 0.05% vs fluocinonide 0.05% ointment in 4% hydroxyethyl cellulose gel vs placebo, all with miconazole gel and chlorhexidine; lesions resolved in 75%, 25%, and 0%; plasma cortisol showed no significant systemic effect (Oral Dis). Carbone et al. 2009: 0.025% vs 0.05% in a bioadhesive gel, about 15 per arm, no statistical difference (J Oral Pathol Med). No trial of a 0.025% rinse was found.
- Fluocinonide: Polizzi et al. 2024, n=47, 0.05% gel vs placebo, 6-month follow-up; outcomes favored fluocinonide (abstract).
- Dexamethasone: Villa et al. 2020, open-label phase II, 24 randomized, commercial solution 0.5 mg/5 mL vs dexamethasone in Mucolox; both improved, larger REU reduction with Mucolox (6 vs 4.3); preliminary, and the protocol lists PCCA as sponsor (OOOO; trial protocol). Georgaki et al. 2022, n=32, dexamethasone 2 mg/5 mL swish and spit three times daily for 4 weeks vs cyclosporine; more clinical improvement and more candidiasis with dexamethasone (Med Oral).
- Betamethasone: UK oral medicine practice dissolves a 500 microgram soluble tablet in 10 to 20 mL of water as a mouthwash, off-label (BISOM); that is about 0.025 to 0.05 mg/mL. Bayview's 0.025% rinse is 0.25 mg/mL, a higher concentration, prepared to the prescriber's order. No randomized trial of a betamethasone rinse in oral lichen planus was found.
- Tacrolimus: Corrocher et al. 2008, double-blind, n=32, 0.1% tacrolimus vs 0.05% clobetasol ointment four times daily for 4 weeks; better response with tacrolimus, though the authors state other studies are needed before it can be recommended in clinical practice; initial worsening of burning in 56.3% of the tacrolimus arm (first 2 days); blood tacrolimus undetectable (J Clin Periodontol). Utz et al. 2022, retrospective, 0.03% tacrolimus rinse, 57 patients (98% previously on topical steroids): objective remission 28%, 62%, 87%, and 97% at 3, 6, 12, and 24 months; 4 patients (7%) developed squamous cell carcinoma during follow-up, not attributed to the drug in the abstract (JEADV). No published trial of a 0.1% rinse was found.
Safety and follow-up:
- Candidiasis in 13.6% of 315 steroid-treated patients; the antifungal prevention strategies used did not differ significantly (Marable et al. 2016).
- Transmucosal clobetasol absorption confirmed in a 10-patient study (Varoni et al. 2012). Iatrogenic Cushing syndrome and secondary adrenal insufficiency after about 12 months of a compounded clobetasol 0.05% mouthwash (with clotrimazole 1% and lignocaine 2%; 15 mL, 5 minutes, once daily); the HPA axis had recovered when checked 2 months after withdrawal (Lin et al. 2024). The dental paste label notes reversible HPA axis suppression with systemic absorption of topical corticosteroids (label).
- Malignant transformation: 0.44% with strict diagnostic criteria (33 studies, 12,838 patients; higher with smoking and alcohol) (Idrees et al.) to 1.43% (97 studies, 36,889 patients; higher with dysplasia, tobacco, alcohol, tongue site, atrophic or erosive forms, and HCV) (González-Moles and Ramos-García). Follow-up at least yearly by a practitioner familiar with the disease, and an initial biopsy when the lesions are not reticulated (French guidelines 2022); others suggest 6-monthly review in severe disease and 3-monthly with dysplasia (Rotaru et al. 2020).
- Hepatitis C: the French guidelines recommend testing when risk factors are present (French guidelines 2022); an older US review suggested screening all patients with lichen planus (Am Fam Physician 2011).
What Bayview compounds (2026 fills):
- Mouth rinses (swish and spit): clobetasol propionate 0.025% in a mucoadhesive base or 0.05%; fluocinonide 0.05%; triamcinolone acetonide 0.1%, 0.2%, or 0.4% preservative-free; betamethasone 0.025%; tacrolimus 0.03% or 0.1% anhydrous suspension.
- Adhesive pastes and gels: clobetasol propionate 0.05% dental paste; lidocaine 1% / clobetasol 0.05% oral gel in a mucoadhesive base; fluocinonide 0.05% oral adhesive paste.
- Dexamethasone: the manufactured 0.5 mg/5 mL solution is dispensed when it fits; a compounded rinse in another strength or base is prepared on prescription.
- Writing the prescription: the medicine, strength, and base (aqueous or mucoadhesive), the amount per rinse and how long to swish, how often, the length of the course, an ICD-10 code for the diagnosis, the quantity, and refills. For a compounded product that matches or can substitute for a manufactured strength, state the patient-specific change and the significant difference it makes.
Licensed to dispense in RI, MA, CT, NJ, NH, FL, ME, and PA. Ordering and account setup are covered on our for providers page.
This information is about prescription medications and is not medical advice. Compounded medications are prescription-only and are not FDA-approved. Your prescriber determines whether a mouth rinse or paste is appropriate and sets the medicine, strength, and schedule.
