What are the treatment options for aphthous ulcers?

Treatment of Aphthous Ulcers

Topical treatments should be used as first-line therapy for aphthous ulcers, including 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 primary treatment for accessible lesions 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 lidocaine to affected area not more than 3-4 times daily 2
• After applying, wash hands with soap and water 2
• Do not use on large areas, cut, irritated or swollen skin 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

Protective Barriers

• Apply white soft paraffin ointment to lips every 2 hours 1
• Use mucoprotectant mouthwashes (e.g., Gelclair) three times daily 1
• Consider adhesive patches containing glycyrrhiza (licorice) extract which can reduce lesion duration, size, and pain 4

Oral Hygiene

• 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
• For dry mouth, recommend sugarless chewing gum, candy, or salivary substitutes 1

Second-Line Management for Refractory Cases

Intralesional and Systemic Steroids

• For ulcers that don't respond to topical therapy, consider intralesional steroid injections (triamcinolone weekly, total dose 28 mg) 1
• 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, 3

Systemic Medications

• For recurrent aphthous stomatitis (RAS), try colchicine as first-line systemic therapy 1, 5
• Consider levamisole for reducing ulcer frequency and duration in patients with minor RAS 6
• For severe cases, consider thalidomide, though its use is limited by frequent adverse effects 7, 3
• Other options include azathioprine, interferon-alpha, TNF-alpha inhibitors, or apremilast in selected cases 1

Preventive Measures

Dietary Modifications

• Avoid hard, acidic, and salty foods 5
• Avoid toothpastes containing sodium lauryl sulfate 5
• Avoid alcohol and carbonated drinks 5
• Address any nutritional deficiencies (iron, folates) that may contribute to recurrent aphthous stomatitis 7

Special Considerations

Underlying Conditions

• Investigate for associated conditions in recurrent aphthous stomatitis, including:
  • Gastrointestinal diseases (celiac disease, inflammatory bowel diseases) 7
  • Immune disorders (HIV infection, neutropenia) 7, 6
  • Behçet's disease (characterized by recurrent bipolar aphthosis) 7

Treatment Algorithm Based on Severity

1. Minor aphthous ulcers (most common):

   • Begin with topical treatments (steroids, anesthetics, protective barriers) 1, 3
   • If no response within 7 days, consider short course of systemic therapy 5

2. Major aphthous ulcers:

   • Start with aggressive topical therapy 3
   • Add systemic corticosteroids if inadequate response 1, 3
   • Consider immunomodulatory drugs for refractory cases 3

3. Herpetiform aphthous ulcers:

   • Similar approach to minor ulcers but may require more aggressive therapy 7
   • Consider antimicrobial mouthwashes in addition to standard therapy 6

Cautions

• Discontinue topical treatments and consult a doctor if condition worsens, redness is present, irritation develops, or symptoms persist for more than 7 days 2
• Systemic medications should be reserved for severe cases that do not respond to topical agents 6, 5
• Thalidomide and other immunosuppressive agents should only be used for refractory or particularly severe oral aphthous ulcers 5