What is the recommended dose of prednisone (corticosteroid) for treating aphthous stomatitis?

Prednisone Dosing for Aphthous Stomatitis

For highly symptomatic aphthous stomatitis, systemic prednisone should be administered as a high-dose pulse of 30-60 mg (or 1 mg/kg) daily for 1 week followed by dose tapering over the second week. 1

Treatment Algorithm Based on Severity

Mild to Moderate Aphthous Stomatitis

1. First-line: Topical treatments

   • Sodium bicarbonate containing mouthwash (4-6 times daily)
   • Topical high-potency corticosteroids:
     • Dexamethasone mouth rinse (0.1 mg/ml)
     • Clobetasol gel/ointment (0.05%) for accessible lesions

2. If inadequate response to topical therapy:

   • Consider intralesional steroid injection (triamcinolone) for persistent ulcers

Severe or Highly Symptomatic Aphthous Stomatitis

1. Systemic corticosteroids:
   • Prednisone 30-60 mg daily (or 1 mg/kg) for 1 week
   • Followed by tapering over the second week
   • Consider concurrent topical therapy for enhanced effect

Detailed Administration Guidelines

Prednisone Tapering Schedule

For a patient starting at 40-60 mg daily:

• Week 1: 40-60 mg daily
• Week 2: Gradual taper (e.g., reduce by 10 mg every 2-3 days)
• Complete the course within 2 weeks

Important Considerations

• Duration: Short-term use (2 weeks total) minimizes adverse effects while providing rapid symptom control 1, 2
• Monitoring: Watch for steroid-related side effects, particularly in patients requiring repeated courses
• Contraindications: Assess for conditions that may be exacerbated by corticosteroids (diabetes, hypertension, osteoporosis)

Evidence Analysis

The ESMO clinical practice guidelines specifically recommend systemic corticosteroids for highly symptomatic aphthous ulcers, with a high-dose pulse of prednisone/prednisolone (30-60 mg or 1 mg/kg) for 1 week followed by tapering over the second week 1. This approach is designed to bring symptoms under control quickly.

Clinical trials support this recommendation, showing that systemic prednisone (starting at 25 mg daily with gradual tapering) provides effective pain relief and accelerates ulcer healing compared to placebo 2. While the study by Femiano et al. used a longer tapering schedule (over 2 months), the ESMO guidelines recommend a shorter course to minimize adverse effects while maintaining efficacy.

Adjunctive Treatments

• Pain management: Consider topical anesthetics (viscous lidocaine 2%) or NSAIDs for pain relief
• Maintenance therapy: After resolution, some patients benefit from prophylactic topical corticosteroids to prevent recurrence 3
• For recurrent cases: Consider steroid-sparing agents for long-term management

Common Pitfalls to Avoid

1. Prolonged systemic steroid use: Extended courses increase risk of adverse effects without additional benefit
2. Inadequate initial dosing: Insufficient doses may fail to control symptoms effectively
3. Abrupt discontinuation: Always taper systemic steroids to prevent withdrawal symptoms
4. Overlooking underlying causes: Consider evaluation for systemic conditions associated with aphthous stomatitis (e.g., Behçet's disease, inflammatory bowel disease)

By following this evidence-based approach with appropriate prednisone dosing, most patients with aphthous stomatitis should experience rapid symptom relief and healing of ulcers.