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TREATMENTS

TREATMENT OPTIONS ARE DISCUSSED IN THE  IN THE CONTEXTS OF:

  • Most likely to induce remission (with dosing and safety discussion)

  • Topical options

  • Less reliable anecdotal options


*Disclaimer: risks represent the major considerations but are not all-inclusive.

MOST LIKELY TO INDUCE REMISSION:

Prednisone

  • Dosing: 60mg by mouth daily for 3 days, taper by 10mg every 2 days. May require longer durations of higher dose. May require long-term therapy with 5-10mg daily.

  • Safety considerations: infection, osteoporosis, diabetes, gastritis/GI bleeding, Cushingoid appearance, hypothalamic-pituitary-adrenal axis suppression, cataracts, skin atrophy (easy bruising), osteonecrosis of the hip, hypertension, mood disorder (tearfulness, mania), psychosis, glaucoma, myopathy, and arrhythmias.

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Cyclosporine

  • Dosing: 5mg/kg/day by mouth in divided doses (i.e., 2.5mg/kg in the am and 2.5mg/kg in the pm). If possible, do not discontinue abruptly (requires approximately 2 week taper by 50-100mg increments).

  • Safety considerations: renal damage (elevated creatinine), hypertension, infection, low magnesium, high potassium, gingival hypertrophy, hypertrichosis, and malignancy.

OTHER POTENTIALLY SUCCESSFUL OPTIONS:

Valacyclovir

  • Dosing: 1g by mouth 3 times daily. Once EM is controlled, some people do well with as little as 500mg daily.

  • Safety considerations: essentially none (lower dosing in severe renal insufficiency).

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Famciclovir​

  • Dosing: 500mg po 3 times daily. Once EM is controlled, some people do well with as little as 500mg daily.

  • Safety considerations: essentially none.


Tofacitinib​

  • Dosing: 5-10mg by mouth twice daily. Once EM is controlled, some people do well with as little as 5mg daily.

  • Safety considerations: At 10mg twice-daily, risk of blood clots, infection, cancer, and neutropenia. At lower doses, these risks are less likely but still present.

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Upadacitinib​

  • Dosing: 15mg by mouth once daily.

  • Safety considerations: Risk of blood clots, infection, cancer, and neutropenia.


Apremilast​

  • Dosing: 30mg by mouth twice daily with rapid titration from 10mg to 60mg (start 10mg daily increase by 10mg every day until 60mg daily). In cases where rapid control is desired, may start 30mg from day one.

  • Safety considerations: Diarrhea, depression, and headache. Half the dose in severe renal insufficiency.

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Thalidomide​

  • Dosing: 50-100mg by mouth daily.

  • Safety considerations: Birth defects, peripheral neuropathy, neutropenia, blood clots, and leg swelling.

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Etancercept​

  • Dosing: 50mg subcutaneously two times per week.

  • Safety considerations: Infection, exacerbation of multiple sclerosis, cancer, and reactivation of tuberculosis.

SAFETY PROFILES MOST DANGEROUS TO LEAST DANGEROUS:

*Order is not exact, and is in the judgment of the author
Cyclosporine
Prednisone (long term)
Thalidomide
Tofacitinib
Upadacitinib
Etanercept
Apremilast
Prednisone (short term)
Famciclovir
Valacyclovir

TOPICAL OPTIONS:

Corticosteroids
Pimecrolimus
Tacrolimus
Crisaborole
Lidocaine gel
Magic mouthwash (lidocaine, diphenhydramine, aluminum/magnesium hydroxide vs sucralfate)

OPTIONS WITH ANECDOTAL REPORTS OF SUCCESS:

Antimalarials
Human immunoglobulin
Interferon-alpha
Rituximab
Tamoxifen
Zinc Sulfate
Cimetidine
Dapsone
Azathioprine
Levamisole

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