Trichloroacetic Acid Promising for the Treatment of Persistent Oral Mucosal Lesions in Pemphigus Vulgaris

The use of topical trichloroacetic acid (TCA) 33% as treatment for persistent old refractory oral mucosal lesions in patients with pemphigus vulgaris (PV) shows promise in individuals with PV who are otherwise in clinical remission, according to study results published in the Journal of the American Academy of Dermatology.¹

The investigators sought to explore the efficacy of topical TCA 33% — a caustic agent that has been utilized as an inexpensive treatment for patients with aphthous stomatitis² — in patients with persistent buccal lesions associated with PV, an autoimmune bullous disease. The oral mucosa are usually affected in PV, with the delayed healing of oral lesions presenting a significant challenge, particularly in the buccal mucosa.³ Although the use of systemic treatments and intralesional corticosteroids has been shown to accelerate the healing process in patients with the disease, these therapies may not be effective for all persistent PV lesions.

The researchers applied topical TCA 33% monthly to lesions that were proven to be unresponsive to a variety of systemic and topical agents. They painted the border of the lesion with a cotton-tipped swab, making certain to avoid dripping during application. A white frost usually appears within a few seconds of the application. Patients typically experience a transient mild burning sensation from the treatment. Some improvement was noted in patients with persistent PV lesions as early as 2 to 3 weeks after beginning TCA application, which can be repeated monthly based on the patient outcome.

No worsening of the lesions or serious adverse events were reported in treated patients. The most important factor to consider is patient selection, as the use of topical TCA is not recommended in patients who have active disease.

The investigators concluded that the application of topical TCA monthly in patients with persistent oral PV lesions is a safe and effective treatment for patients otherwise in clinical remission.

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References

1. Mahmoudi H, Balighi K, Tavakolpour S, Daneshpazhooh M, Chams-Davatchi C. Trichloroacetic acid as a treatment for persistent oral mucosal lesions in pemphigus vulgaris [published online September 6, 2018]. J Am Acad Dermatol. doi:10.1016/j.jaad.2018.08.039

2. Al-Abbasi AM. Efficacy of topical trichloroacetic acid and hydrogen peroxide for aphthous ulcers. Gomal J Med Sci (GJMS). 2010;8(2):105-107.

3. Kumar S, De D, Handa S, et al. Identification of factors associated with treatment refractoriness of oral lesions in pemphigus vulgaris. Br J Dermatol. 2017;177(6):1583-1589.