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Abstract: This is a 30-year-old female patient who found white lines on both the left and right sides of her mouth about 2 years ago, and it was very painful if she ate a little spicy food, and it was more severe recently before she considered coming to the hospital and was diagnosed with oral lichen planus after the relevant examination at night. After 1 month of medication, the pain was significantly reduced, normal diet was resumed, and the condition stabilized.
Basic information】Female, 30 years old
Disease Type】Stomatous Lichen Planus
Hospital】Shenyang Hospital of Integrative Medicine
Date of Consultation】August 2021
Treatment plan】Oral medication (vitamin AD soft capsule, lycopene soft capsule) + topical medication (vitamin A acid cream)
Treatment Period】4 weeks of outpatient treatment
Treatment effect] Pain was significantly reduced and the condition stabilized.
I. Initial consultation
The patient is female, 30 years old, and she reported that she has had this condition for almost 2 years, because she has always had mouth ulcers, such as when she brushes her teeth and accidentally stabs her gums with the toothbrush, it will develop into ulcers, so she has never been to the hospital. The patient said he felt a burning sensation and dryness when he touched it with his tongue, and sometimes it was a little itchy, so he was initially diagnosed as having oral lichen planus.
Second, the treatment process
According to the patient’s symptoms and clinical diagnosis, the patient was first given vitamin AD soft capsule orally to replenish vitamins, and lycopene soft capsule to help improve the patient’s immunity and promote the recovery of the disease, in addition to topical application of vitamin A cream to control the pain symptoms, and the patient was instructed to standardize the medication and review regularly.
III. Treatment effect
After 2 weeks of standardized medication, the patient was seen to have lost most of the white papules on both sides of the mouth, and the ulcers had basically healed, and the scope of some red and swollen areas had also been reduced; after 4 weeks of follow-up, the patient complained that the pain had basically disappeared, and he had recently followed the doctor’s advice to eat a lighter diet, and the white lines on both sides of the mouth had basically subsided, and his condition had basically recovered.
IV. Notes
I am pleased with the improvement of the patient’s condition, but also need to advise patients to pay attention to the following matters in daily life.
1. Pay attention to oral hygiene, brush your teeth in the morning and evening, and rinse your mouth after meals to ensure a clean mouth.
2, maintain a healthy work and rest, do not stay up late, maintain adequate sleep, appropriate exercise, enhance physical fitness, improve body immunity.
3, the diet must avoid spicy and stimulating food, eat lighter, to avoid stimulating the oral mucosa again.
4, usually keep a happy mood; maintain an optimistic and positive attitude, do not be too impatient, do not be too nervous, maintain a relaxed state of mind.
V. Personal insight
This patient’s oral lichen planus is a bit delayed, so the treatment period is relatively long, at the very beginning of the onset, the patient should come to see the doctor. But clinically many patients with oral lichen planus feel that it is just a mouth ulcer at the beginning and will be fine after a few days, so they let the lesion become more and more serious.
The cause of oral lichen planus is very complex, but it has a lot to do with the usual diet and emotions, so the patient should be advised to avoid eating during the illness, or it will recur, and then keep a relaxed state of mind, do not be anxious and impatient, mood swings can easily cause oral lichen planus.