What is the initial workup and treatment for recurrent aphthous (canker sore) ulcers?

Workup and Treatment for Recurrent Aphthous Ulcers (Canker Sores)

The initial workup and treatment for recurrent 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

Initial Diagnostic Workup

• Perform a thorough clinical examination to confirm diagnosis of recurrent aphthous ulcers and rule out other conditions 1
• Consider blood tests for patients with severe or frequent recurrences, including complete blood count, iron studies, folate and vitamin B12 levels, to rule out underlying nutritional deficiencies 2
• For ulcers lasting over 2 weeks or not responding to treatment, consider biopsy to rule out other conditions 1
• Evaluate for potential systemic associations such as celiac disease, inflammatory bowel diseases, HIV infection, or Behçet's disease in patients with severe or frequent recurrences 2

First-Line Treatment

Topical Corticosteroids

• Apply topical steroids as first-line therapy for accessible lesions 1
• For localized ulcers, use clobetasol gel or ointment (0.05%) mixed in equal amounts with Orabase applied directly to affected areas daily 1, 3
• For widespread or difficult-to-reach ulcers, use betamethasone sodium phosphate 0.5 mg in 10 ml water as a 3-minute rinse-and-spit preparation four times daily 1, 3
• Consider fluticasone propionate nasules diluted in 10 ml of water twice daily as an alternative 4

Pain Management

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

Protective Measures

• Apply white soft paraffin ointment to lips every 2 hours if affected 1, 3
• Use mucoprotectant mouthwashes (e.g., Gelclair) three times daily to form a protective coating over ulcerated surfaces 1, 3

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, 3
• Consider diluting 0.2% chlorhexidine mouthwash by up to 50% to reduce soreness 1

Secondary Infection Management

• Take oral and lip swabs if bacterial or candidal secondary infection is suspected 1
• For candidal infection, treat with nystatin oral suspension 100,000 units four times daily for 1 week, or miconazole oral gel 5-10 ml held in the mouth after food four times daily for 1 week 1, 3

Second-Line Treatment for Refractory Cases

Intralesional Steroids

• Consider weekly intralesional triamcinolone injections (total dose 28 mg) in conjunction with topical clobetasol for ulcers that don't resolve with topical treatment 1, 4

Systemic Therapy

• 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, 4
• For recurrent aphthous stomatitis, try colchicine as first-line systemic therapy, especially for cases with erythema nodosum or genital ulcers 1, 2
• Consider tacrolimus 0.1% ointment applied twice daily for 4 weeks for recalcitrant cases 4
• For severe cases unresponsive to other treatments, consider immunomodulators such as thalidomide, but use with caution due to potential adverse effects 6, 7

Common Pitfalls and Considerations

• Avoid premature tapering of corticosteroids before disease control is established 1
• Recognize that systemic interventions are often reserved for patients unresponsive to topical treatments 8
• Refer patients to a specialist for oral ulcers lasting more than 2 weeks or not responding to 1-2 weeks of treatment 1
• Avoid hard, acidic, and salty foods that may exacerbate symptoms 7
• Avoid toothpastes containing sodium lauryl sulfate, alcohol, and carbonated drinks 7

Treatment Algorithm

1. Start with topical corticosteroids and pain management
2. Add protective measures and maintain good oral hygiene
3. If no improvement after 7-10 days, consider intralesional steroids
4. For severe or recurrent cases, progress to systemic therapy
5. For cases unresponsive to standard therapy, refer to a specialist for consideration of immunomodulatory agents