What is the best way to manage aphthous ulcers?

Management of Aphthous Ulcers

Topical corticosteroids are the first-line treatment for aphthous ulcers, with 0.1% triamcinolone acetonide in orabase applied 2-4 times daily until healing. 1

Initial Assessment and Diagnosis

• Identify ulcer characteristics:

  • Duration, shape, location, number, and appearance
  • Rule out serious causes if an ulcer persists beyond 2 weeks
  • Consider biopsy for persistent ulcers to exclude malignancy 1

• Consider differential diagnoses:

  • Pemphigus vulgaris, bullous pemphigoid, tuberculosis
  • Fungal infections, Crohn's disease
  • Behçet's disease (characterized by recurrent bipolar aphthosis) 2

Treatment Algorithm

Step 1: Topical Treatments (First-Line)

1. Topical anesthetics for pain relief:

   • Lidocaine viscous 2% solution 1
   • Barrier preparations (Gengigel or Gelclair) 1

2. Topical corticosteroids:

   • 0.1% triamcinolone acetonide in orabase (2-4 times daily) 1
   • Alternative options: clobetasol 0.05% ointment, betamethasone sodium phosphate, fluticasone propionate 1

3. Other topical agents:

   • Sucralfate suspension 1, 3
   • Antiseptic agents like triclosan 3
   • Tacrolimus 0.1% ointment for resistant cases 1

Step 2: For Severe or Recurrent Cases

If topical treatments fail, consider systemic medications:

1. Colchicine - particularly effective for recurrent aphthous stomatitis 2, 3
2. Pentoxifylline 3
3. Short courses of systemic corticosteroids (prednisolone) for severe cases 1, 3

Step 3: For Refractory Cases

For particularly severe or refractory cases, especially those associated with Adamantiades-Behçet disease:

• Consider immunosuppressive agents under specialist supervision 3
• Thalidomide is highly effective but limited by adverse effects 2

Prevention and Self-Care Measures

• Oral hygiene:

  • Use soft toothbrush and mild non-foaming toothpaste
  • Rinse with saline solution 4-6 times daily
  • Use alcohol-free mouthwash 1

• Dietary modifications:

  • Avoid known triggers:
    • Hard, acidic, spicy, or salty foods
    • Toothpastes containing sodium lauryl sulfate
    • Alcohol and carbonated drinks 1, 3
  • Stay hydrated 1

Monitoring and Follow-up

• Regular monitoring for persistent cases
• Follow-up every 3-6 months for recurrent symptomatic cases
• Immediate evaluation for any ulcer persisting beyond 2 weeks 1

Red Flags Requiring Urgent Assessment

• Induration or fixation of the lesion
• Unexplained bleeding
• Cervical lymphadenopathy
• Lesion growth despite treatment
• Persistent numbness or paresthesia
• History of tobacco or heavy alcohol use with persistent lesion 1

Treatment Considerations for Different Types of Aphthous Ulcers

• Minor aphthous ulcers: Typically respond well to topical treatments
• Herpetiform aphthous ulcers: May require more aggressive topical therapy
• Major aphthous ulcers: Often require combination of topical and systemic treatments 2, 4

Remember that treatment should be tailored to the severity of the problem, including frequency of ulcers, intensity of pain, and responsiveness to treatment. Effective management relieves pain, lessens functional impairment, and reduces recurrence frequency and severity 3.