How to treat aphthous ulcers?

Management of Aphthous Ulcers

The initial approach to oral aphthous ulcers should begin with topical treatments 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 Topical Treatments

• Apply topical steroids as first-line therapy for accessible oral aphthous ulcers 1, 2:

  • For localized ulcers: clobetasol gel or ointment (0.05%) applied to dried mucosa twice daily 1, 2
  • For widespread or difficult-to-reach ulcers: dexamethasone mouth rinse (0.1 mg/ml) 1
  • Betamethasone sodium phosphate 0.5 mg dissolved in 10 ml water as a rinse-and-spit preparation four times daily 1, 2
  • Fluticasone propionate nasules diluted in 10 ml of water twice daily 2

• Use topical pain management strategies 1, 2:

  • Topical anesthetic mouthwashes (viscous lidocaine 2%) before meals 1
  • Benzydamine hydrochloride rinse or spray every 3 hours, particularly before eating 1
  • Barrier preparations such as Gengigel mouth rinse/gel or Gelclair for pain control 2
  • Topical NSAIDs (e.g., amlexanox 5% oral paste) for severe pain 1

• Implement supportive oral hygiene measures 1:

  • 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
  • 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 1, 2:

  • Tacrolimus 0.1% ointment applied twice daily for 4 weeks 2
  • Intralesional steroid injections (triamcinolone weekly, total dose 28 mg) 1, 2

• For highly symptomatic or recurrent ulcers, consider systemic therapy 1, 3:

  • Systemic corticosteroids (prednisone/prednisolone 30-60 mg or 1 mg/kg for 1 week with tapering over the second week) 1, 2
  • Colchicine as first-line systemic therapy, especially for recurrent aphthous stomatitis with erythema nodosum or genital ulcers 1, 4
  • For severe refractory cases: azathioprine, interferon-alpha, TNF-alpha inhibitors, or apremilast 1

Treatment Based on Ulcer Type

• Minor aphthous ulcers (most common):

  • Primarily managed with topical treatments and supportive care 3, 4
  • Usually heal within 7-14 days without scarring 3

• Major aphthous ulcers:

  • More aggressive treatment approach with combination of topical and systemic therapies 5
  • May persist for several weeks to months and can cause scarring 5

• Herpetiform aphthous ulcers:

  • Similar management to minor ulcers but may require more intensive topical therapy 3

Common Pitfalls to Avoid

• Avoid premature tapering of corticosteroids before disease control is established 1
• Don't overlook concurrent candidal infection, which may require treatment with nystatin oral suspension or miconazole oral gel 2
• Avoid hard, acidic, salty foods, toothpastes containing sodium lauryl sulfate, alcohol, and carbonated drinks that may exacerbate ulcers 4
• Don't delay referral to a specialist for ulcers lasting more than 2 weeks or not responding to 1-2 weeks of treatment 1

Lifestyle Modifications

• Identify and avoid trigger foods that may precipitate ulcers 4
• Consider dietary supplements if nutritional deficiencies are suspected (iron, folates, vitamin B12) 3
• Maintain good oral hygiene with gentle brushing and non-irritating toothpaste 4

Over-the-Counter Options

• Glycyrrhiza (licorice) extract patches have been shown to reduce lesion duration, size, and pain 6
• Cyanoacrylate products can provide temporary relief but may have adverse effects 6