What is the management and treatment for aphthous ulcers?

Management of Aphthous Ulcers

Topical treatments are the first-line therapy for aphthous ulcers, including topical steroids, barrier agents, and pain control measures, followed by systemic therapies for refractory cases based on the underlying cause and severity of the ulcers. 1

First-Line Management

Topical Steroids

• Apply topical steroids as first-line therapy for accessible oral aphthous ulcers 1
• For localized ulcers, use clobetasol gel or ointment (0.05%) 1
• For widespread or difficult-to-reach ulcers, use dexamethasone mouth rinse (0.1 mg/ml) 1
• Consider betamethasone sodium phosphate 0.5 mg in 10 ml water as a rinse-and-spit preparation four times daily 1

Pain Management

• Use topical anesthetic mouthwashes (viscous lidocaine 2%) before meals to reduce pain 1, 2
• Apply benzydamine hydrochloride rinse or spray every 3 hours, particularly before eating 1
• For severe pain, consider topical NSAIDs (e.g., amlexanox 5% oral paste) 1, 3

Oral Hygiene and Supportive Care

• Clean the mouth daily with warm saline mouthwashes 1
• Use antiseptic oral rinses twice daily (e.g., 1.5% hydrogen peroxide or 0.2% chlorhexidine digluconate) 1, 2
• Apply white soft paraffin ointment to lips every 2 hours 1
• Use mucoprotectant mouthwashes (e.g., Gelclair) three times daily 1

Lifestyle Modifications

• Avoid hard, acidic, and salty foods that may irritate ulcers 3
• Avoid toothpastes containing sodium lauryl sulfate 3
• Limit alcohol and carbonated drinks 3

Second-Line Management for Refractory Cases

Intralesional Steroids

• For ulcers that don't respond to topical therapy, consider intralesional steroid injections (triamcinolone weekly, total dose 28 mg) 1

Systemic Therapies

• Consider systemic corticosteroids for highly symptomatic or recurrent ulcers (prednisone/prednisolone 30-60 mg or 1 mg/kg for 1 week with tapering over the second week) 1, 2
• For recurrent aphthous stomatitis, try colchicine as first-line systemic therapy, especially for erythema nodosum or genital ulcers 1, 3
• In severe cases, consider azathioprine, pentoxifylline, or TNF-alpha inhibitors 1, 3

Special Considerations

Recurrent Aphthous Stomatitis (RAS)

• RAS is defined by recurrence of oral aphthous ulcers at least 4 times per year 4
• Investigate for underlying conditions such as celiac disease, inflammatory bowel diseases, nutritional deficiencies (iron, folates), or immune disorders 4, 5
• Thalidomide is highly effective for severe RAS but should be used cautiously due to potential adverse effects 4, 2

Behçet's Disease

• Consider Behçet's disease in patients with recurrent bipolar aphthosis (oral and genital ulcers) 4
• Colchicine with topical treatments is the standard first-line therapy 4
• More aggressive immunosuppression may be needed for refractory cases 1, 4

PFAPA Syndrome

• In children with periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis, consider PFAPA syndrome 5
• Systematic oral follow-up is required to monitor for signs of ulceration 5

Classification of Aphthous Ulcers

• Minor aphthous ulcers: Most common (80-90% of cases), small (<1 cm), shallow ulcers that heal within 7-14 days without scarring 4, 6
• Major aphthous ulcers: Larger (>1 cm), deeper, more painful, and may take weeks to months to heal, often with scarring 4, 6
• Herpetiform aphthous ulcers: Multiple small clustered ulcers that may coalesce 4, 6

Differential Diagnosis

• Oral herpes simplex is the primary differential diagnosis 6
• Other conditions to consider include oral lichen planus, pemphigus, pemphigoid, erythema multiforme, and oral malignancies 4
• Any solitary chronic ulcer should be biopsied to rule out squamous cell carcinoma 4