Why are steroids given for aphthous ulcers?

Steroids for Aphthous Ulcers: Rationale and Approach

Topical corticosteroids are considered a first-line treatment for aphthous ulcers because they effectively reduce inflammation, decrease pain, and promote faster healing by suppressing the local immune response that contributes to ulcer formation and persistence. 1

Mechanism of Action

Corticosteroids work in aphthous ulcers by:

• Suppressing local inflammation through inhibition of inflammatory mediators
• Reducing pain by decreasing inflammatory processes
• Promoting faster healing by modulating the immune response
• Preventing recurrence when used appropriately

Treatment Algorithm

First-Line Treatment

• Topical corticosteroids: 0.1% triamcinolone acetonide in orabase, applied 2-4 times daily until healing (typically within 7-14 days) 1
  • Alternative options include:
    • Clobetasol 0.05% ointment
    • Betamethasone sodium phosphate
    • Fluticasone propionate
    • Dexamethasone ointment (shown to significantly reduce ulcer size and pain compared to placebo) 2

Application Method

1. Dry the affected area
2. Apply a small amount of corticosteroid directly to the ulcer
3. Apply after meals and before bedtime
4. Continue until healing occurs (typically 7-14 days)

For Severe or Recurrent Cases

• For ulcers that don't respond to topical treatments:
  • Consider short courses of systemic corticosteroids 1
  • Consider colchicine or pentoxifylline as steroid-sparing alternatives 3
  • Thalidomide is highly effective but should be reserved for severe cases due to toxicity concerns 3

Clinical Evidence

Research demonstrates the efficacy of corticosteroids for aphthous ulcers:

• Dexamethasone ointment showed significant reduction in ulcer size (7.167 ± 6.3415 mm² vs 4.346 ± 7.0666 mm² with placebo) and pain levels (5.623 ± 1.9570 vs 4.940 ± 2.2449) with a healing ratio of 83.33% compared to 54.70% with placebo 2
• Triamcinolone acetonide ointment demonstrated superior efficacy (86.7% positive response) compared to alternative treatments like phenytoin syrup (53.3% positive response) 4

Important Considerations and Precautions

• Duration of use: Limit corticosteroid use to short durations (generally <8-12 weeks) to avoid adverse effects 5
• Monitoring: Watch for signs of secondary infection, as steroids may mask infection or suppress immune response
• Contraindications: Exercise caution in patients with:
  • Active viral, fungal, or bacterial infections
  • Immunocompromised status
  • History of steroid-induced complications

Adjunctive Measures

While using corticosteroids, recommend:

• Good oral hygiene with soft toothbrush and mild non-foaming toothpaste
• Avoiding triggers like hard, acidic, spicy, or salty foods
• Avoiding toothpastes containing sodium lauryl sulfate
• Limiting alcohol and carbonated drinks 1
• Using topical anesthetics (like lidocaine viscous 2% solution) for pain management 1

When to Refer or Consider Alternative Diagnoses

• If ulcers persist beyond 2 weeks despite treatment
• For ulcers associated with systemic symptoms
• When ulcers are unusually large or numerous
• If there's suspicion of malignancy (induration, fixation, unexplained bleeding)

Proper use of topical corticosteroids represents an evidence-based approach to managing aphthous ulcers that effectively addresses pain, promotes healing, and improves quality of life for affected patients.