Table 3 Guidelines for management of... | American Society of Hematology

Table 3

Guidelines for management of oral cGVHD

	Treatment	Considerations
Oral mucosal cGVHD	Generalized disease Dexamethasone solution 0.5 mg/5 mL, 5 mL swish 5 minutes and spit, 2-4 times/day Clobetasol 0.05% solution • Budesonide mouthwash (3 mg/10 mL) Tacrolimus 0.1% solution Focal disease (eg, solitary painful ulcers) Fluocinonide 0.05% gel, 2-4 times/day Clobetasol 0.05% gel, 2-4 times/day Intralesional triamcinolone therapyLips Tacrolimus 0.1% ointment, 2-4 times/day	Instruct patients to wait 10-15 minutes after topical therapy before eating/drinking Gels can be applied with gauze and left in place 10-15 minutes Solutions: begin with dexamethasone, if inadequate response after 2-4 wks (4 times a day), substitute with clobetasol (budesonide can also be used). If after 2-4 wks still inadequate control, add tacrolimus and use equal parts with clobetasol as a single combined rinse Secondary candidiasis, typically occurs in first week, in addition to treatment most will require prophylaxis. Prophylaxis regimens include daily topical antifungal therapy or fluconazole 200 mg once/wk
Salivary gland cGVHD
Xerostomia	Salivary stimulants (gum/candy) Oral-moisturizing agents Sialogogue therapy Pilocarpine 5 mg 3 times a day Cevimeline 30 mg 3 times a day	Sugar-free or xylitol-containing gum/candy Sialogogues may take 8-12 wks for full efficacy Avoid sialogogues in patients with pulmonary disease
Dental caries	Good oral hygiene Avoid sugary foods/drinks Topical fluoride therapy Remineralization therapy Regular dental visits	See Table 4 for detailed guidelines
Candidiasis	Fluconazole	Topical steroid therapy increases risk of candidiasis
	Disinfect removable prosthesis nightly	Antifungal prophylaxis for recurrent candidiasis
Sclerotic cGVHD	Physical therapy	Condition is generally progressive and requires ongoing therapy
	Intralesional steroid therapy
	Surgery to disrupt mucosal bands

	Treatment	Considerations
Oral mucosal cGVHD	Generalized disease Dexamethasone solution 0.5 mg/5 mL, 5 mL swish 5 minutes and spit, 2-4 times/day Clobetasol 0.05% solution • Budesonide mouthwash (3 mg/10 mL) Tacrolimus 0.1% solution Focal disease (eg, solitary painful ulcers) Fluocinonide 0.05% gel, 2-4 times/day Clobetasol 0.05% gel, 2-4 times/day Intralesional triamcinolone therapyLips Tacrolimus 0.1% ointment, 2-4 times/day	Instruct patients to wait 10-15 minutes after topical therapy before eating/drinking Gels can be applied with gauze and left in place 10-15 minutes Solutions: begin with dexamethasone, if inadequate response after 2-4 wks (4 times a day), substitute with clobetasol (budesonide can also be used). If after 2-4 wks still inadequate control, add tacrolimus and use equal parts with clobetasol as a single combined rinse Secondary candidiasis, typically occurs in first week, in addition to treatment most will require prophylaxis. Prophylaxis regimens include daily topical antifungal therapy or fluconazole 200 mg once/wk
Salivary gland cGVHD
Xerostomia	Salivary stimulants (gum/candy) Oral-moisturizing agents Sialogogue therapy Pilocarpine 5 mg 3 times a day Cevimeline 30 mg 3 times a day	Sugar-free or xylitol-containing gum/candy Sialogogues may take 8-12 wks for full efficacy Avoid sialogogues in patients with pulmonary disease
Dental caries	Good oral hygiene Avoid sugary foods/drinks Topical fluoride therapy Remineralization therapy Regular dental visits	See Table 4 for detailed guidelines
Candidiasis	Fluconazole	Topical steroid therapy increases risk of candidiasis
	Disinfect removable prosthesis nightly	Antifungal prophylaxis for recurrent candidiasis
Sclerotic cGVHD	Physical therapy	Condition is generally progressive and requires ongoing therapy
	Intralesional steroid therapy
	Surgery to disrupt mucosal bands