What is the 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. 1

First-Line Management

Topical Steroids

• Apply topical steroids as first-line therapy for accessible oral aphthous 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 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

Protective Measures

• Apply white soft paraffin ointment to lips every 2 hours 1
• Use mucoprotectant mouthwashes (e.g., Gelclair) three times daily 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

Second-Line Management for Refractory Cases

Advanced Topical Therapy

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

Systemic Therapy

• 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
• For recurrent aphthous stomatitis, try colchicine as first-line systemic therapy, especially for erythema nodosum or genital ulcers 1, 3
• Consider azathioprine, interferon-alpha, TNF-alpha inhibitors, or apremilast in selected severe cases 1

Lifestyle Modifications

• Avoid hard, acidic, and salty foods 3
• Avoid toothpastes containing sodium lauryl sulfate 3
• Minimize consumption of alcohol and carbonated drinks 3
• For dry mouth, recommend sugarless chewing gum, candy, or salivary substitutes 1

Treatment Algorithm Based on Severity

Mild Cases (1-3 small ulcers)

1. Topical anesthetics (lidocaine) for immediate pain relief 1, 2
2. Topical steroids (clobetasol gel 0.05%) applied directly to lesions 1
3. Antiseptic mouthwashes twice daily 1

Moderate Cases (Multiple or larger ulcers)

1. Topical anesthetics before meals 1, 2
2. Dexamethasone mouth rinse (0.1 mg/ml) 1
3. Protective barrier agents 1
4. Consider topical NSAIDs 1

Severe Cases (Extensive, painful, or recurrent ulcers)

1. Combination of topical therapies 1
2. Consider systemic corticosteroids for short-term use 1, 4
3. For recurrent cases, consider colchicine 1, 3
4. Refer to specialist if ulcers persist beyond 2 weeks despite treatment 1

Special Considerations

Recurrent Aphthous Stomatitis (RAS)

• Defined by recurrence of oral aphthous ulcers at least 4 times per year 5
• May be associated with systemic conditions including celiac disease, inflammatory bowel diseases, nutritional deficiencies, or immune disorders 5
• Requires more aggressive management with combination therapy 5, 3

When to Refer

• Ulcers lasting over 2 weeks 1
• Ulcers not responding to 1-2 weeks of treatment 1
• Suspicion of underlying systemic disease 5
• Severe or debilitating cases 3

Common Pitfalls to Avoid

• Premature tapering of corticosteroids before disease control is established 1
• Failure to consider underlying systemic conditions in recurrent cases 5
• Overuse of systemic therapies for mild cases 3
• Inadequate pain management leading to poor nutrition and hydration 1, 2