Oral disease is what persists in pemphigus vulgaris after the skin has settled, and it is what patients stop mentioning. They adapt: soft food, one side of the mouth, no citrus. Asked whether things are better, they say yes, because the skin is.
So do not ask 'how is your mouth'. Look. Buccal mucosa, palate, gingival margins, and the posterior pharynx if the voice has changed — and ask specifically what they have stopped eating in the last month. A patient who has quietly moved to a soft diet has active disease whatever the skin score says.
This matters more now that treatment decisions are increasingly framed around remission on minimal steroid. Missed mucosal activity is the commonest reason a patient is tapered too fast and relapses.
- Examine the oral cavity at every review, with a light, not by history alone.
- Ask what foods have been dropped since the last visit.
- Record mucosal and cutaneous activity separately when documenting response.
- Hoarseness or odynophagia warrants laryngeal assessment rather than a dose increase alone.
- Do not begin a steroid taper on skin clearance alone.
Why it matters
The activity that decides whether a taper fails is the activity the patient has stopped reporting.
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