First-line therapy: All patients suspected of having OHL should first be evaluated by KOH preparation to exclude a diagnosis of oral candidiasis as well as consideration of a cause for immunocompromise or immunosuppression in the affected patient. OHL and oral candidiasis may also occur concurrently in any given patient.
- Patients with OHL must be evaluated for the presence of HIV infection and other forms of immunosuppression if HIV tests are negative. Successful HIV treatment with anti-retroviral medications will likely result in resolution of OHL.
- In addition, treat the frequently associated thrush, if present, with clotrimazole troches (first-line) or oral nystatin suspension.
- Topical tretinoin 0.1% cream (such as Atralin, Avita, Refissa, Renova, Retin-A, Retin-A Micro), adapalene cream (such as Differin), or tazarotene (such as Tazorac) may be applied twice daily. Topical acyclovir ointment applied to the lesion 4 times daily may also result in resolution of lesions.
- Oral acyclovir 2.0 to 3.2 g per day (400 mg 5 times daily, or 800 mg 4 times daily) for 10-14 days. OHL will resolve with intravenous acyclovir, but this is rarely indicated.
- Chronic suppression with retinoic acid or topical acyclovir may be used. However, as OHL is totally asymptomatic and hidden, suppressive therapy has no proven benefit.
- Failure to evaluate for HIV infection or other cause of immunocompromise.
- Side effects from oral acyclovir are rare. They include rashes and mild GI upset. Intravenous acyclovir may precipitate in the kidney and decrease renal function, so renal function tests should be followed.
- HIV-positive individuals also may develop true precancerous or cancerous leukoplakia like oral lesions. The diagnosis of OHL should be considered only when in its characteristic location (lateral tongue bilaterally). A biopsy is required to establish the diagnosis of OHL when seen at other locations in the oral cavity.
- Epstein-Barr virus serologies play no role in the management or diagnosis of OHL.