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Oral Tacrolimus Safety — SCE Dermatology MCQ

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HardInflammatory DermatosesOral Tacrolimus SafetySCE Dermatology

A 50-year-old man has erosive oral lichen planus refractory to topical Clobetasol mouthwash. His dermatologist considers adding topical Tacrolimus 0.1% oral paste. What is the specific concern with long-term topical Tacrolimus on oral mucosa?

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Correct answer: A — Theoretical concern about increased oral SCC risk with prolonged topical calcineurin inhibitor use on a surface already predisposed to malignancy (OLP is a WHO potentially malignant disorder); careful follow-up is needed

Topical Tacrolimus (0.03-0.1%) is an effective second-line treatment for erosive oral LP. However, there is a theoretical concern about prolonged topical calcineurin inhibitor use on oral mucosa: (1) OLP is already classified by WHO as a potentially malignant disorder with ~0.5-1% annual SCC transformation risk; (2) calcineurin inhibitors suppress local T-cell immune surveillance; (3) case reports of oral SCC in patients using topical Tacrolimus for OLP (though causality is unproven). BAD guidelines recommend using topical TCIs for oral LP when topical corticosteroids are insufficient, but with ongoing clinical surveillance for malignant change. The benefits of disease control typically outweigh the theoretical carcinogenic risk.

Reference: BAD 2019 LP Guidelines; Cochrane OLP