“The problem with the usual liquid nystatin preparations used for oral thrush is they contain a lot of sugar. They are not good for patients with Sjögren’s syndrome,” Dr. Alan N. Baer said at a symposium sponsored by the American College of Rheumatology.
“We use the nystatin vaginal tablets, which don’t contain the excess sugar. The patient places a nystatin vaginal tablet in the mouth twice a day, allowing it to dissolve slowly. It’s not the greatest taste in the world, but patients get tremendous benefit from clearing this infection,” explained Dr. Baer, director of the multidisciplinary Jerome L. Greene Sjögren’s Syndrome Center at Johns Hopkins University in Baltimore.
Clotrimazole vaginal tablets can be employed as topical therapy in identical fashion,he added.
In patients with Sjögren’s syndrome who have mild salivary hypofunction, oral fluconazole or another systemic antifungal agent is effective therapy. The vaginal tablets are reserved for patients with severe chronic hyposalivation that precludes the achievement of therapeutic levels of the systemic antifungal in the mouth.
Chronic erythematous candidiasis is distinct from pseudomembranous candidiasis, which is by far the most common form of oral candidiasis in settings other than Sjögren’s syndrome. Pseudomembranous candidiasis features distinctive white plaques or specks that can be wiped off. Chronic erythematous candidiasis, in contrast, is marked by flat red patches. It affects one-third of Sjögren’s syndrome patients who have chronic hyposalivation. Symptoms include a mucosal burning sensation, metallic taste, and intolerance to spicy or acidic foods.
Sjögren’s syndrome patients commonly have dry mouth, which also is responsive to conservative measures. Saliva substitutes can bring relief, as can oral pilocarpine or cevimeline, but relatively few patients seem to stick with any of these measures long term. Instead, they often prefer simply to carry a water bottle and drink from it frequently. If they choose this option, it’s important to tell them to take only small sips – just enough to moisten the mouth. Large quantities will dilute the beneficial mucins in the oral cavity, thereby aggravating their condition, according to Dr. Baer.
Dry eyes are the other troublesome sicca symptom that’s extremely common in Sjögren’s syndrome. A humidifier in the bedroom is beneficial. Artificial tears are important. Topical therapy with corticosteroid or cyclosporine eye drops is very helpful. Oral fish oil and flaxseed oil have also been shown to be beneficial, and patients should be encouraged to take one or the other, he continued.
One of the enduring mysteries of Sjögren’s syndrome has been the cause of the sicca symptoms that are disease hallmarks. The explanation can’t lie in straightforward autoimmune destruction of the salivary and lacrimal glands, because the severity of sicca symptoms correlates poorly with histopathologic findings. Investigators at the National Institutes of Health have recently provided evidence to suggest that salivary gland inflammation and dysfunction may be two distinctly different pathophysiologic processes.
“It’s quite likely that inflammation occurring around the salivary gland ducts can impair transmission of impulses down the nerve fibers, leading to the exaggerated glandular dysfunction, as opposed to simply glandular destruction,” he said.
Dr. Baer reported having no relevant financial involvements.