What is the treatment for recurrent oral ulcers?

Treatment of Recurrent Oral Ulcers

The first-line treatment for recurrent oral ulcers should be topical steroids, with clobetasol gel or ointment (0.05%) for localized lesions and dexamethasone mouth rinse (0.1 mg/ml) for widespread or difficult-to-reach ulcers. 1

First-Line Topical Treatments

• Apply betamethasone sodium phosphate 0.5 mg in 10 ml water as a rinse-and-spit preparation four times daily for immediate relief 1, 2
• For localized ulcers, use clobetasol 0.05% ointment mixed in 50% Orabase applied twice weekly to dried mucosa 1, 2
• Use topical anesthetic mouthwashes (viscous lidocaine 2%) before meals to manage pain 1
• Apply benzydamine hydrochloride rinse or spray every 3 hours, particularly before eating to reduce pain 1
• For severe pain, consider topical NSAIDs such as amlexanox 5% oral paste 1, 3
• Use mucoprotectant mouthwashes (e.g., Gelclair) three times daily to create a protective barrier 1, 2

Oral Hygiene and Supportive Care

• Clean the mouth daily with warm saline mouthwashes to maintain hygiene 1
• Use antiseptic oral rinses twice daily (e.g., 1.5% hydrogen peroxide or 0.2% chlorhexidine digluconate) 1
• Avoid hard, acidic, salty foods, toothpastes containing sodium lauryl sulfate, alcohol, and carbonated drinks 4
• Apply white soft paraffin ointment to lips every 2 hours if affected 1

Second-Line Treatments for Refractory Cases

• For ulcers that don't respond to topical therapy, consider intralesional steroid injections (triamcinolone weekly, total dose 28 mg) 1, 2
• Try tacrolimus 0.1% ointment applied twice daily for 4 weeks for recalcitrant oral aphthous ulcers 2
• Consider colchicine as first-line systemic therapy, especially for recurrent aphthous stomatitis with erythema nodosum or genital ulcers 5, 1, 6

Systemic Therapy for Severe Cases

• For highly symptomatic or recurrent ulcers, consider systemic corticosteroids (prednisone/prednisolone 30-60 mg or 1 mg/kg for 1 week with tapering over the second week) 1, 2
• In severe cases where local treatment is insufficient, consider immunomodulatory drugs like thalidomide, though its use is limited due to toxicity and cost 7, 6
• For Behçet's syndrome with recurrent oral ulcers, start with topical steroids and colchicine, progressing to immunosuppressives for refractory cases 5, 1

Special Considerations

• Treat patients with concurrent candidal infection with nystatin oral suspension or miconazole oral gel 2
• Biopsy any solitary chronic ulcer to rule out squamous cell carcinoma 6
• For ulcers associated with systemic conditions (e.g., inflammatory bowel disease, celiac disease, HIV), treat the underlying condition 8, 6
• Avoid premature tapering of corticosteroids before disease control is established 1

Treatment Algorithm Based on Severity

1. Mild cases (1-3 small ulcers):

   • Topical steroids and pain management
   • Oral hygiene measures
   • Avoidance of triggering factors 1, 4

2. Moderate cases (multiple ulcers or frequent recurrences):

   • More potent topical steroids
   • Consider intralesional steroid injections
   • Evaluate for underlying conditions 1, 2, 8

3. Severe cases (major aphthous ulcers, disabling symptoms):

   • Systemic corticosteroids
   • Consider colchicine or other immunomodulatory drugs
   • Multidisciplinary approach if associated with systemic disease 5, 1, 6