What is the recommended treatment for mouth ulcers in patients with Crohn's disease?

Treatment of Mouth Ulcers in Crohn's Disease

For patients with Crohn's disease experiencing mouth ulcers, topical therapy with 3% diclofenac in 2.5% hyaluronan is recommended as first-line treatment due to its proven efficacy in providing sustained pain relief for up to 6 hours. 1

Understanding Mouth Ulcers in Crohn's Disease

Mouth ulcers (oral aphthous ulcers) are a common extraintestinal manifestation of Crohn's disease. They can cause significant pain and discomfort, affecting a patient's quality of life and ability to eat and drink properly.

Treatment Approach

First-Line Topical Treatments:

1. Topical Diclofenac Preparation

   • 3% diclofenac in 2.5% hyaluronan gel provides significant pain reduction (35-52%) lasting 2-6 hours after application 1
   • Apply directly to ulcers as needed for pain relief
   • Note: While this is an NSAID, topical application minimizes systemic absorption and risk of exacerbating Crohn's disease

2. Alternative Topical Options:

   • Hyaluronan gel alone (provides initial pain relief but not sustained relief) 1
   • Viscous lidocaine (provides immediate but short-term relief) 1

Symptomatic Relief Measures:

• Sitz baths - Warm water soaks for 10-15 minutes, 2-3 times daily for perianal symptoms 2
• Witch hazel pads - For mild perianal irritation and discomfort 2

Important Considerations

Medications to Avoid:

• Systemic NSAIDs (ibuprofen, naproxen, aspirin) should be avoided as they may trigger flares and worsen gut inflammation 2
• For systemic pain relief, acetaminophen (paracetamol) is the preferred analgesic for patients with Crohn's disease 2

Underlying Disease Management:

The most effective long-term strategy for managing mouth ulcers in Crohn's disease is controlling the underlying inflammatory condition:

1. For mild to moderate disease:

   • Mesalamine products may be used for mild to moderate colonic Crohn's disease 3
   • Budesonide (9 mg/day) for mild to moderate ileal and/or right colonic Crohn's disease 4

2. For moderate to severe disease:

   • Corticosteroids (prednisone 40-60 mg/day) for rapid symptom control 4
   • Anti-TNF therapy (infliximab, adalimumab) for induction and maintenance of remission 4
   • Consider vedolizumab or ustekinumab in patients who fail to respond to other therapies 4

Monitoring and Follow-up

• Evaluate response to topical therapy within 24-48 hours
• If mouth ulcers persist despite topical treatment and adequate control of Crohn's disease, consider consultation with oral medicine specialist
• Assess overall Crohn's disease activity and adjust systemic therapy as needed

Nutritional Considerations

• Avoid spicy, acidic, or rough-textured foods that may irritate mouth ulcers
• Ensure adequate hydration and nutrition despite oral pain
• Consider vitamin B12, folate, vitamin D, and albumin levels to assess nutritional status 3

By combining effective topical therapy for immediate pain relief with appropriate systemic management of Crohn's disease, most patients can achieve significant improvement in oral symptoms and quality of life.