Abstract
This study evaluates the effectiveness of a twice daily tacrolimus swish-and-spit treatment regimen for geographic tongue.
Geographic tongue, commonly called benign migratory glossitis, is a chronic, immune-mediated, inflammatory condition affecting 1% to 2.5% of the world population.1,2 It is characterized clinically by relapsing and remitting erythematous patches with a white edge that migrate across the tongue and histologically by epithelial edema and neutrophilic microabscess formation.1,3 Although considered as a benign condition, geographic tongue can cause disfiguring lesions or burning pain aggravated by specific foods. Treatments are limited, cost prohibitive, and currently lack sufficient outcome data.2 This study examines a technique that has successfully managed oral lichen planus and consists of a twice daily swish-and-spit solution of a 1-mg tacrolimus capsule dissolved in 500 mL of water.4 This study evaluated the effectiveness of this regimen for geographic tongue.
Methods
This retrospective medical record review was approved by the Wake Forest Baptist Health institutional review board, Winston-Salem, North Carolina. Patient consent was waived. Inclusion criteria included patients 18 years or older diagnosed with geographic tongue. Patients presented with classic patches of depapillation and raised serpiginous borders as well as no extralingual inflammation to the Wake Forest Dermatology Clinic in Winston-Salem, North Carolina, between January 1, 2008, and January 1, 2018. The primary outcome measure was attending physician–documented clinical improvement. Demographics collected included age, sex, and race. Race/ethnicity data were collected to characterize the study population. Exclusion criteria included patients with other oral conditions (including herpes simplex virus infections and oral lichen planus), taking systemic steroids or immunomodulators, with fewer than 2 visits available for review, or who did not use the oral tacrolimus swish-and-spit regimen.
The treatment regimen involved dissolving the contents of a 1-mg tacrolimus capsule into 500 mL of water. Patients were instructed to swish the oral solution for 2 minutes before spitting the solution for disposal. This regimen should be performed twice daily.
Results
Twenty patients met the inclusion criteria (mean [range] age, 59 years [18-86]; white, 19 [95%], white/Native American, 1 [5%]; women, 13 [65%]). Patients described the following symptoms: irritation, burning, redness, soreness, pain, or stinging (Table). Before initiating tacrolimus solution, 13 patients (65%) reported inadequate response to topical corticosteroid treatment, which was continued as combination therapy in 11 of these patients (85%). Additional combination therapies continued or initiated included clotrimazole troches (10 mg) and gabapentin (100-200 mg daily) (Table). At follow-up, 14 patients (70%) reported improvement, 5 patients (25%) reported no improvement, and 1 patient (5%) had an unclear response. Adverse events most commonly included a raw and tender mouth after treatment and an irritated tongue from the clotrimazole troches.
Table. Patient Characteristics and Treatment Outcomes for Geographic Tongue.
| Patient No. | Sex (Age, y) | Prior Treatments | Disease Duration | Symptoms | Tacrolimus Swish-and-Spit Treatment Plus Combination Therapies | Improvement | ||
|---|---|---|---|---|---|---|---|---|
| Topical Steroid | Clotrimazole troche | Gabapentin | ||||||
| 1 | Female (60s) | None | 1 mo | Irritation | No | No | No | Unclear |
| 2 | Female (70s) | Prednisone, topical corticosteroids | >2 y | Burning | Yes | Yes | Yes | No |
| 3 | Male (60s) | Nystatin, topical corticosteroids | 4 mo | Redness, soreness | Yes | Yes | No | No |
| 4 | Female (40s) | None | 1.5 y | Burning, irritation | Yes | Yes | Yes | Yes |
| 5 | Male (40s) | Topical corticosteroids, nystatin | 9 mo | Burning | Yes | No | No | Yes |
| 6 | Female (20s) | None | Unknown | Burning | No | Yes | No | Yes |
| 7 | Male (50s) | Clotrimazole troche, antibiotics | >2 y | Sensitivity, soreness | No | Yes | No | Yes |
| 8 | Male (70s) | Prednisone, topical corticosteroids | 8 mo | Burning | No | Yes | No | Yes |
| 9 | Female (60s) | Topical corticosteroids | 5 y | Burning, pruritus | Yes | Yes | Yes | Yes |
| 10 | Female (50s) | Dexamethasone solution | 3 y | Burning | Yes | Yes | Yes | Yes |
| 11 | Female (50s) | Magic mouthwash, topical corticosteroidsa | 1 y | Pain | Yes | No | No | Yes |
| 12 | Female (30s) | Magic mouthwash, topical corticosteroids, and gabapentina | 1.5 y | Pain | Yes | Yes | Yes | Yes |
| 13 | Female (teens) | Prednisone, clotrimazole troche | 1.5 y | Burning | No | Yes | No | No |
| 14 | Female (60s) | Clotrimazole troche, gabapentin | 1 y | Burning | No | Yes | Yes | No |
| 15 | Male (50s) | Fluconazole, topical corticosteroids, cepacol/peroxide, clotrimazole troche, and gabapentin | 6 mo | Burning, pain | Yes | Yes | Yes | Yes |
| 16 | Male (60s) | Topical corticosteroids, magic mouthwash, and chlorohexidinea | 6 mo | Burning, pain | No | Yes | Yes | Yes |
| 17 | Female (80s) | None | 3 mo | Burning, pain | No | Yes | No | Yes |
| 18 | Male (70s) | Topical corticosteroids, clotrimazole troche, fluconazole, and prednisone | >2 mo | Pain | Yes | Yes | No | No |
| 19 | Female (70s) | Gabapentin, fluconazole, clotrimazole troche, tacrolimus ointment, and topical corticosteroids | 5 y | Burning, pain | Yes | Yes | Yes | Yes |
| 20 | Female (70s) | Tacrolimus ointment, topical corticosteroids, mupirocin, clotrimazole troche, gabapentin, and donepezil | >2 y | Stinging, pain | Yes | Yes | Yes | Yes |
Magic mouthwash is a nonstandardized solution used in the treatment of oral mucositis, most commonly containing diphenhydramine, viscous lidocaine, and magnesium hydroxide/aluminum hydroxide.
Discussion
Topical tacrolimus treatment is used for cutaneous diseases including atopic dermatitis and pyoderma gangrenosum but requires additives such as propylene carbonate to adequately absorb into the stratum corneum.5 Fortunately, the mucosal surface of the tongue contains highly vascular fungiform papillae that are nonkeratinized. These features reduce barriers to absorption and increase the local permeation of tacrolimus.6 Based on these pharmacologic principles, tacrolimus swish and spit, in our experience, offers a cost-effective treatment for geographic tongue. This regimen reduces the risk of systemic effects because inadvertent consumption of a single dose is approximately 0.01 mg of tacrolimus.
In a 2018 systematic review of all treatments for geographic tongue, only 8 of 150 cases had reported improvement, 3 of which were treated with topical tacrolimus ointment.2 Other treatments with favorable outcomes included systemic diphenhydramine, systemic cyclosporin, lidocaine, and ozone therapy. Limitations of this study include the retrospective design, potential confounding therapy, and lack of comparative control group.
Conclusions
Considering the improvement rate, low cost, ease of use, and nonsystemic route, tacrolimus 2 mg/L swish-and-spit solution may be a beneficial treatment option for patients with symptomatic geographic tongue. In addition, focally applied topical steroids such as fluocinonide gel (0.05%) can be used for breakthrough erosions, 10-mg clotrimazole troches daily for candida prophylaxis, and gabapentin (100-200 mg) at bedtime for continued burning or discomfort.
References
- 1.Assimakopoulos D, Patrikakos G, Fotika C, Elisaf M. Benign migratory glossitis or geographic tongue: an enigmatic oral lesion. Am J Med. 2002;113(9):751-755. doi: 10.1016/S0002-9343(02)01379-7 [DOI] [PubMed] [Google Scholar]
- 2.de Campos WG, Esteves CV, Fernandes LG, Domaneschi C, Júnior CAL. Treatment of symptomatic benign migratory glossitis: a systematic review. Clin Oral Investig. 2018;22(7):2487-2493. doi: 10.1007/s00784-018-2553-4 [DOI] [PubMed] [Google Scholar]
- 3.Picciani BL, Domingos TA, Teixeira-Souza T, et al. Geographic tongue and psoriasis: clinical, histopathological, immunohistochemical and genetic correlation—a literature review. An Bras Dermatol. 2016;91(4):410-421. doi: 10.1590/abd1806-4841.20164288 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Olivier V, Lacour JP, Mousnier A, Garraffo R, Monteil RA, Ortonne JP. Treatment of chronic erosive oral lichen planus with low concentrations of topical tacrolimus: an open prospective study. Arch Dermatol. 2002;138(10):1335-1338. doi: 10.1001/archderm.138.10.1335 [DOI] [PubMed] [Google Scholar]
- 5.Herkenne C, Naik A, Kalia YN, Hadgraft J, Guy RH. Effect of propylene glycol on ibuprofen absorption into human skin in vivo. J Pharm Sci. 2008;97(1):185-197. doi: 10.1002/jps.20829 [DOI] [PubMed] [Google Scholar]
- 6.Ishibashi M, Tojo G, Watanabe M, Tamabuchi T, Masu T, Aiba S. Geographic tongue treated with topical tacrolimus. J Dermatol Case Rep. 2010;4(4):57-59. [DOI] [PMC free article] [PubMed] [Google Scholar]