Oral lichenoid lesion associated with nicotine pouch use: a case report

Nicotine pouches (NPs) have gained popularity as tobacco-free alternatives to conventional tobacco products. Emerging evidence has described several NP-associated oral mucosal alterations, predominantly localized hyperkeratotic or white lesions, mucosal erythema, and edema. However, the potential association between NP use and OLLs oral lichenoid lesions remains poorly characterized. This report presents a case of OLL associated with habitual NP use. A 62-year-old European man presented with a persistent red-and-white lesion involving the maxillary anterior gingiva at his habitual NP placement site. He had used an extra-strength, menthol-flavored NP product containing 20 mg/g of nicotine (approximately 12 mg per pouch) approximately five times daily for 1.5 years. Histopathological examination demonstrated features consistent with lichenoid mucositis without epithelial dysplasia or malignancy, and a clinicopathological diagnosis of OLL was favored. The patient was advised to discontinue NP use and was treated with 0.1% fluocinolone acetonide in Orabase together with 2% miconazole oral gel for antifungal prophylaxis, resulting in clinical improvement. However, he subsequently resumed NP use and relocated the pouch to the mandibular anterior vestibule, where a new area of mucosal erythema developed. At the 3-month follow-up, the maxillary lesion had nearly resolved, while the mandibular erythema had diminished. The patient reported reduced NP use and remained on maintenance topical corticosteroid therapy during this period. To our knowledge, this is the first reported case of an OLL associated with habitual NP use in which the diagnosis was supported by histopathological examination. The temporal and topographic relationship between NP placement and the observed mucosal changes supports a possible association between local NP exposure and OLL, although causality cannot be established from a single case. Given the recognized malignant potential of OLLs, long-term surveillance of affected patients is warranted. Further longitudinal studies are needed to determine whether NP-associated OLLs carry a risk of malignant transformation and to clarify the long-term oral health consequences of NP use.