A 75-year-old man has had oral lichen planus for three years. Dry mouth has resulted in multiple dental cavities and extractions. Trials of oral hydroxychloroquine (Plaquenil)triamcinolone 0.1% (Oralone) dental paste, dexamethasone 4 mg IM, and tacrolimus (Protopic) have been unsuccessful. He takes fluconazole (Diflucan) for periodic bouts of moniliasis.
—Kenneth G. Wong, MD, Bakersfield, Calif.

Oral lichen planus can be a difficult condition to treat. Many of the therapies you tried are first-line therapies I use, including triamcinolone dental paste and topical tacrolimus. I might try a higher-potency steroid, such as clobetasol ointment or gel. If this fails, you could consider a systemic therapy, such as methotrexate. Recently, the biologic agents alefacept (Amevive) and efalizumab (Raptiva) have been shown to have some efficacy when used off-label in the treatment of this condition.
—Jeffrey M. Weinberg, MD