Usage of antihistamines and topical corticosteroids in the management of geographic tongue

P Poornachitra; Jayanth K Vadivel

doi:10.4103/jiaomr.jiaomr_219_21

ORIGINAL ARTICLE

Year : 2022 | Volume : 34 | Issue : 2 | Page : 156-160

Usage of antihistamines and topical corticosteroids in the management of geographic tongue

P Poornachitra, Jayanth K Vadivel
Department of Oral Medicine and Radiology, Saveetha Dental College and Hospital, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, Tamil Nadu, India

Date of Submission	01-Aug-2021
Date of Decision	03-Nov-2021
Date of Acceptance	31-May-2022
Date of Web Publication	22-Jun-2022

Correspondence Address:
Jayanth K Vadivel
Department of Oral Medicine and Radiology, Saveetha Dental College and Hospital, Saveetha Institute of Medical and Technical Sciences, Saveetha University
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jiaomr.jiaomr_219_21

Abstract

Geographic tongue (GT) is a benign inflammatory condition of the tongue with map-like areas of erythema. In symptomatic cases, pharmacotherapy is advised to improve quality of life and reduce chances of recurrence. Aim: The study aimed to compare the usage of antihistamines and topical corticosteroids in the management of symptomatic geographic tongue. Objective: The objective was to evaluate the most common drug used in symptomatic geographic tongue management and assess the association between patient gender and drugs given. Materials and Methods: The treatment data of patients (n = 88) was collected from Dental Information Archival System with data from June 2019 to February 2021. The usage of antihistamines and topical steroids was assessed over two weeks to relieve clinical symptoms. Results: The association between drug type, drug name, and reduction in the clinical symptoms after two weeks of the review was statistically significant, with an X₂ value of 9.132 at a P value of 0.010 (p < 0.05). The association between drug type, drug name, and gender was not statistically significant (p > 0.05). 38.6% of cases were prescribed Diphenhydramine maleate syrup. It was followed by Betamethasone Mouthwash which was used for 31.8% of cases. Triamcinolone acetonide and Chlorpheniramine tablets were prescribed for 15.9%and 13.6%patients, respectively. Conclusion: Antihistamines should be the first drug type of choice in treating symptomatic GT. Topical steroids could be considered an adjunct or standalone second drug type of choice.

Keywords: Antihistamine, benign migratory glossitis, burning sensation, geographic tongue, topical corticosteroid, wandering rash of tongue

How to cite this article:
Poornachitra P, Vadivel JK. Usage of antihistamines and topical corticosteroids in the management of geographic tongue. J Indian Acad Oral Med Radiol 2022;34:156-60

How to cite this URL:
Poornachitra P, Vadivel JK. Usage of antihistamines and topical corticosteroids in the management of geographic tongue. J Indian Acad Oral Med Radiol [serial online] 2022 [cited 2022 Jul 1];34:156-60. Available from: https://www.jiaomr.in/text.asp?2022/34/2/156/347917

Introduction

Geographic tongue (GT) or Benign Migratory Glossitis or erythema migrans or wandering rash of the tongue is an annular lesion affecting the dorsum and margin of the tongue.^[1] Its prevalence is 1–2.5%,^[2] and a high incidence of about 39.4% occurs in 20–29 years.^[3] Females are more commonly affected than males, with a ratio of 1.5:1.^[3] or 2:1.^[4]

Suggested etiological factors are

Impaired tissue breakdown creating hyper mature areas [white line] with hypomature or atrophic areas [red line].^[5] Lymphocyte infiltration in connective tissue increases mitotic activity
Fungi,^[6] psoriasis,^[7] allergies,^[8] psychological stress,^[9] diabetes mellitus,^[10] genetic predisposition^[11]
Pregnant women,^[12] oral contraceptives, where hormones increase vascularization and susceptibility to pre-established inflammatory responses.^[13]

It manifests in three patterns:^[14] (1) patchy areas of desquamated filiform papillae; (2) areas delineated by raised, white, circinate (ring-shaped) borders; and (3) patchy areas of desquamated filiform papillae bordered by an erythematous band of inflammation. It is characterized by a period of exacerbation and remission with different durations and disappears to reappear at a different location.^[15] The patterns are modeled as a reaction-diffusion system and the tongue's surface determines the lesion's shape.^[16]

The disorder is usually asymptomatic. But in symptomatic cases, burning sensation and soreness are present.^[17] This study aimed to compare the usage of antihistamines and topical corticosteroids in the management of geographic tongue. The objective was to evaluate the most common drug used and assess the association between patient gender and drugs.

Materials and Methods

In this retrospective study, the archived patient records were collected using Dental Information Archiving Software [DIAS] and uploaded after obtaining informed written consent. The data were assessed from June 2019 to February 2021. The total sample size was calculated using Gpower [Gpower 3.1] using a key article where the effect size was determined to be 0.5, and by keeping the power as 80%, the sample size obtained was 80. Institutional ethical clearance was obtained (IHEC/SDC/OMED-2002/21/51), and the study was conducted conforming to the ethical norms and standards of the declaration of Helsinki. All known cases of the symptomatic geographic tongue (n = 88) consisting of 58 males and 30 females aged 21–74 years were picked up based on sample size estimation by G power.

The patient records were reviewed and analyzed; variables recorded were the age, gender, variant of geographic tongue, the site of the lesion, and the therapy used. The study's internal validity was established as the data had been collected from a verifiable and standardized database. The external validity was established as the data was from a duplicatable clinical setup. These patients had complained of burning sensation or soreness, or both. Informed consent had been obtained from patients before initiating the treatment.

Antihistamines or topical corticosteroids have been used in pharmacotherapeutic management. The prescribed antihistamines and topical corticosteroids were either Diphenhydramine maleate syrup (50 mg, i.e., 10 ml twice a day) or Chlorpheniramine tablet (4 mg twice a day) and Triamcinolone acetonide gel (0.1%) or Betamethasone mouthwash (500 micrograms of betamethasone sodium phosphate dissolved in 10 ml of warm water) four times/day, respectively. Patients were advised to refrain from spicy foods during treatment. The patients were assessed over two weeks duration in relieving clinical symptoms.

The data were tabulated in an excel sheet of Microsoft Office Professional Plus 2019, a 64-bit system, and formatted. The data analysis was processed using IBM SPSS (statistical package for the social sciences) 23.0 software (SPSS Inc., Chicago, IL., USA). Chi-square test was used for the statistical analyzes to determine the association between the drug used and two weeks review; and between the drug used and patient gender. The P value < 0.05 was considered statistically significant.

Results

The mean age distribution of the patients is shown In [Table 1]. The mean age was 37.45 ± 11.68 years ranging from 21 to 74 years. The mean age for the males was 36.55 ± 11.68 years, with a minimum of 21 years and a maximum of 67 years. The mean age for the females was 39.20 ± 11.68 years, with a minimum of 21 years and a maximum of 74 years.

Table 1: Mean age (in years) of the patients treated for symptomatic geographic tongue

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The frequency distribution of drug types used in patients for treating symptomatic geographic tongue is depicted in [Figure 1]. Among the 88 patients, the majority of 46 patients accounting for 52.3% of the cases, were prescribed antihistamines. The rest of the 42 patients (47.7%) were given topical corticosteroids. Among the 58 males, 31 (53.4%) males were prescribed Topical corticosteroids and the remaining 27 (46.6%) were prescribed antihistamines. Among the 30 females, 11 (36.7%) were prescribed topical corticosteroids, and 19 (63.3%) were given antihistamines.

Figure 1: Frequency distribution of drug type used in treatment of symptomatic geographic tongue

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The frequency distribution of drug names used in the treatment of geographic tongue is depicted in [Figure 2]. Among the 88 patients, the majority of 34 cases accounting for 38.6% of cases, were prescribed Diphenhydramine maleate syrup. It was followed by Betamethasone Mouthwash which was taken by 28 patients accounting for 31.8% of cases. Triamcinolone acetonide and Chlorpheniramine tablets were prescribed for 14 (15.9%) and 12 (13.6%) patients. Among the 58 males, 23 (39.7%) were given Diphenhydramine maleate syrup, 20 (34.5%) were given Betamethasone MW, and 11 (19%) were given Triamcinolone acetonide, and only 4 (6.9%) were given chlorpheniramine tablets. Among the 30 females, 11 (36.7%) were prescribed Diphenhydramine maleate syrup, and 8 each (26.7% each) were prescribed Chlorpheniramine tablets and Betamethasone MW. Only 3 (10%) were given Diphenhydramine maleate syrup.

Figure 2: Frequency distribution of drug name used in treatment of symptomatic geographic tongue

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The reduction of clinical symptoms during review after two weeks according to gender is depicted in [Figure 3]. Among the 58 males, a reduction in burning sensation and soreness was seen in 24 cases, accounting for 41.4%. Reduction only in burning sensation was seen in 18 (31%) cases, and reduction in only soreness was seen in 16 patients accounting for 27.6% of cases. Among the 30 females, reduction in soreness, reduction in burning sensation, and reduction in both burning sensation and soreness were seen in 10 cases, each accounting for 33.3% of cases each. In 88 patients, the maximum reduction was seen in both burning sensation and soreness in 34 patients accounting for 38.6% of cases. A reduction followed it in a burning sensation in 28 cases accounting for 31.8% of cases. Reduction in only soreness was seen in 26 patients accounting for 29.5% of cases.

Figure 3: Frequency distribution of reduction of clinical symptoms during review after two weeks according to gender. a) total samples, b) Gender

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The association between the two parameters was determined using the Chi-square test [Table 2]. Association between drug name (triamcinolone acetonide, Diphenhydramine maleate syrup, chlorpheniramine tablet, and Betamethasone MW) and reduction in symptoms at two weeks review was statistically significant with X₂ value of 24.145 at a P value of 0.000 (p < 0.05). The association between drug name (triamcinolone acetonide, Diphenhydramine maleate syrup, chlorpheniramine tablet, and Betamethasone MW) and gender (male, female) was not statistically significant. The association between drug type (topical corticosteroids and antihistamine) and reduction in symptoms at two weeks of the review was statistically significant with an X₂ value of 9.132 at a P value of 0.010 (p < 0.05). The association between drug type (topical corticosteroids and antihistamine) and gender was not statistically significant as the P value was 0.135 (p > 0.05).

Table 2: Association between various parameters determined by Chi-square test

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Discussion

Geographic tongue or lingual erythema migrans [ICD-11: 1460387786] is a benign inflammatory condition of the tongue with map-like erythematous areas that are not perpetually size, shape, or location.GT dynamics evolve between three main states: a healed (rest) state, a highly inflamed (excited) state, and healing (recovering) state. It has two features: the anisotropic propagation of lesions on the epithelium of the tongue and the evolution of spiral patterns within recovering regions.

The etiology of this lesion is unknown; however, hereditary and environmental factors play a role. The condition had been hypothesized to be a clinical expression of 20 or more diseases, but no correlation withstands evidence-based reviews. People with Down syndrome have a higher prevalence of geographic tongue.^[18]

In most scenarios, the lesions are asymptomatic, but a few patients might complain of a mild burning sensation with hot, spicy, or acidic foods when the lesions are in the clinically active phase. If sore, this may be noted, especially with acidic foods, walnuts, or some cheese. Recently, a new index called “Geographic Tongue Area and Severity Index [GTASI]” has been developed consistently and accurately to make it valuable for routine assessments, clinical studies, and the determination of appropriate therapy.^[19]

Discomfort can be reduced or prevented by avoiding alcohol, chewing tobacco products, consuming hot, spicy, and sour foods, regular intake of acidic fruits and beverages, using toothpaste that contains tartar control additives with or without heavy flavoring or whitening agents, dried, salty nuts that might exacerbate the underlying condition. Clinical effectiveness has been noted with Cyclosporin, Corticosteroids, Tetracyclines, Vitamins, and Zinc.^[18] Some advocate zinc 200 mg three times daily for three months which may occasionally help.^[20]

In this study, among the 88 patients, 52.3% of the cases were prescribed antihistamines and 47.7% were given topical corticosteroids. 38.6% of cases were prescribed Diphenhydramine maleate syrup, 31.8% were advised Betamethasone Mouthwash, 15.9% were given Triamcinolone acetonide, and 13.6% were given Chlorpheniramine tablets. In symptom alleviation, the maximum reduction was seen in burning sensation and soreness in 38.6% of cases. A reduction followed it in a burning sensation in 31.8% of cases. A reduction in only soreness was seen in 29.5% of cases. By Chi-square test, the association between drug type, drug name, and reduction of symptoms in two weeks review had been shown to be statistically significant (p < 0.05). However, there was no statistically significant (p > 0.05) association between drug type, name, and patient gender.

According to Mehta.,^[15] antihistamines had been shown to treat symptomatic geographic tongue. Elixir of Benadryl, a potent antihistamine, is used in the oral cavity primarily as a mild topical anesthetic agent for symptomatic relief for GT. Antihistamine mouth rinse and a bland diet are recommended for symptomatic relief in certain cases. Topical antihistamine, diphenhydramine elixir 12.5 mg/5 mL diluted 1:4 with water, had been advocated as one of the first-line therapies in the management strategy of GT based on clinical trials with less than 20 subjects.^[21]

However, the role of topical corticosteroids had been well established in literature with evidence-based clinical studies in treating oral lesions.^[22] Though steroids have a better anti-inflammatory response than antihistamines, we noticed that antihistamines were preferred more commonly than topical steroids. This might be because topical steroids carry the burden of immunosuppression, leading to opportunistic infections. Also, its interactions with pre-existing systemic conditions need to be monitored carefully.

Limitations

The limitations were unicentric studies with single ethnicity of the population who reported to this college. Another shortcoming in this study was the alleviation of symptoms was recorded after two weeks only and was not followed up in the long run as it was a benign condition. This study also highlights the importance of conducting case-control or randomized clinical control studies to understand the efficacy of antihistamines compared to topical corticosteroids in treating symptomatic GT.

Prospects

Since GT is a recurrent lesion, it is essential to follow-up long-term, and hence further studies could take this factor while designing the study. The research could also be expanded to a multicentric study with a larger sample size with variant demographics.

Conclusion

The treatment should be administered in symptomatic cases to improve the quality of life and reduce the chances of recurrence. We could advocate those antihistamines should be the first drug type of choice in treating symptomatic GT. However, in improper treatment outcomes, Topical steroids could be considered an adjunct or standalone second drug.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Key message

The study compares the common drugs used in symptomatic geographic tongue management and if any association exists between gender influence and the drugs used.

Financial support and sponsorship

The authors of this article would like to thank Saveetha Dental College and Hospital, Saveetha Institute of Medical and Technical Sciences, Chennai.

Conflicts of interest

There are no conflicts of interest.

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