How to manage canker sores in patients with Mast Cell Activation Syndrome (MCAS)?

From the Guidelines

Managing canker sores in patients with Mast Cell Activation Syndrome (MCAS) requires a comprehensive approach that addresses both the oral lesions and the underlying mast cell reactivity, with a focus on reducing morbidity, mortality, and improving quality of life. To achieve this, patients should use topical treatments such as benzocaine gel (Orajel, 20% concentration applied up to 4 times daily), triamcinolone dental paste (0.1%, applied 2-3 times daily after meals), or salt water rinses (1/2 teaspoon salt in 8 ounces warm water) for immediate relief 1. For more severe cases, prescription options include dexamethasone oral rinse (0.5 mg/5mL, rinse for 2 minutes and spit, 4 times daily) or magic mouthwash formulations containing lidocaine, diphenhydramine, and sometimes steroids. Some key points to consider in managing canker sores in MCAS patients include:

• Identifying and avoiding personal triggers, such as acidic foods, spicy foods, nuts, chocolate, and stress, which can exacerbate symptoms 1
• Maintaining good oral hygiene with a soft-bristled toothbrush and SLS-free toothpaste to prevent trauma to sensitive oral tissues
• Using H1 antihistamines like cetirizine (10mg daily) or fexofenadine (180mg daily), H2 blockers such as famotidine (20mg twice daily), and mast cell stabilizers like cromolyn sodium or quercetin (500mg twice daily) to manage underlying mast cell reactivity 1 This comprehensive approach is supported by recent guidelines, which emphasize the importance of multidisciplinary management and prevention of mast cell activation during surgical procedures 1. By prioritizing the reduction of morbidity, mortality, and improvement of quality of life, and using the most recent and highest quality evidence available, patients with MCAS can effectively manage their canker sores and improve their overall health outcomes.

From the Research

Mast Cell Activation Syndrome (MCAS) and Canker Sores

• Canker sores, also known as aphthous ulcers, can be a symptom of Mast Cell Activation Syndrome (MCAS) 2, 3.
• MCAS is a condition characterized by the excessive activation of mast cells, leading to the release of various mediators, such as histamine, prostaglandin D2, and leukotrienes 2.
• These mediators can cause a range of symptoms, including gastrointestinal issues, skin rashes, and oral ulcers like canker sores 3.

Managing Canker Sores in MCAS Patients

• Treatment of canker sores in MCAS patients typically involves a multi-faceted approach, including avoiding triggers, using antimediator therapies, and managing symptoms 2, 4.
• Antimediator therapies, such as H1 and H2 antihistamines, leukotriene receptor blockers, and sodium cromolyn, can help alleviate symptoms of MCAS, including canker sores 2, 5.
• In some cases, corticosteroids may be used to manage severe or prolonged episodes of mast cell activation 2.

Diagnosis and Classification of MCAS

• The diagnosis of MCAS is based on three criteria: typical clinical signs and symptoms of mast cell activation, increase in tryptase level, and response to antimediator therapy 4.
• Classification of MCAS requires sensitive and specific methodological approaches, including bone marrow studies and predictive models like the Spanish Network on Mastocytosis score 4.
• Gastroenterologists and other healthcare professionals can play a crucial role in diagnosing and managing MCAS, including identifying and treating gastrointestinal symptoms like canker sores 3.