Sir, we write in response to the letter Erosive lichen planus (BDJ 2014; 216: 545).

Erosive and ulcerative lesions of oral lichen planus (OLP) can be persistent and painful;1 therapy is warranted when patients have painful disease that may adversely impact upon quality of life, but effective management of OLP can be challenging.2 The letter's authors presented their recent preliminary experience with betamethasone valerate 0.05% cream (Betnovate), which, they report, seems beneficial in controlling painful symptoms.

This is perhaps not unexpected, as a wide spectrum of corticosteroid formulations including mouthwashes, creams, ointments, sprays and intralesional injections have been reported in the treatment of symptomatic OLP. Nevertheless, there remains a lack of well-designed clinical trials in this field, with a relatively recent systematic review indicating that there is little robust evidence for the efficacy of any single treatment for the management of erosive OLP.3 Although grateful to the authors, we highlight that comprehensive management of OLP can be a significantly more complex matter. For example, the medico-legal responsibility of prescribing, dispensing and administering an agent outwith its licensed indication. It is important that clinicians inform patients of the off-label use of these agents and detail possible side effects.4 Patients should be carefully reviewed for such events. OLP management must also encompass its malignant potential and oral cancer development which may be in up to 3.5% of cases5,6 with essential long-term monitoring of patients to identify and diagnose early dysplastic and malignant changes.7

Any patient with possible OLP should be initially referred to specialists to ensure that the diagnosis is formally confirmed, appropriate treatment is provided and adequate, evidence-based information is given. Simply telling a patient that they are likely to have OLP is often unhelpful and sometimes they can become alarmed after surfing the Internet. Patients' perspective and expectation are also important, as conversations regarding the chronic nature of the disease and associated increased risk of cancer may sometimes become difficult.