What is the treatment for aphthous ulcers?

Treatment of Aphthous Ulcers

Topical corticosteroids should be used as first-line treatment for aphthous ulcers, with betamethasone sodium phosphate 0.5 mg dissolved in 10 mL of water as a rinse-and-spit solution one to four times daily being the most effective option. 1

First-Line Treatments

• Apply high-potency topical corticosteroids as the primary treatment for aphthous ulcers 1, 2
• Options include:
  • Betamethasone sodium phosphate 0.5 mg dissolved in 10 mL of water as a 2-3 minute rinse-and-spit solution one to four times daily 1
  • Fluticasone propionate nasules diluted in 10 mL of water twice daily 1
  • Clobetasol 0.05% ointment mixed in 50% Orabase applied twice weekly to localized lesions on dried mucosa 1
  • Dexamethasone mouth rinse (0.1 mg/ml) for multiple lesions or difficult-to-reach ulcerations 2

Pain Management

• Use bland non-alcoholic, sodium bicarbonate containing mouthwash four to six times daily, increasing frequency up to once per hour if needed 2
• For moderate pain, consider topical NSAIDs (e.g., amlexanox 5% oral paste) 2
• For more severe pain, follow the WHO pain management ladder with:
  • Anesthetic mouthwashes (viscous lidocaine 2%) 2
  • Coating agents 2, 1
  • Systemic analgesics as needed 2
• Consider barrier preparations such as Gengigel mouth rinse/gel or Gelclair for pain control 1

Supportive Measures

• Advise patients to avoid:
  • Hard, acidic, and salty foods 3
  • Toothpastes containing sodium lauryl sulfate 3
  • Alcohol and carbonated drinks 3
• Recommend sugarless chewing gum or candy, salivary substitutes or sialogogues for patients with oral dryness 2

Second-Line Treatments

• For recalcitrant ulcers, consider tacrolimus 0.1% ointment applied twice daily for 4 weeks 1
• For ulcers that don't resolve with topical treatment, consider weekly intralesional triamcinolone (total dose 28 mg) in conjunction with topical clobetasol gel or ointment (0.05%) 2, 1

Systemic Therapy for Severe Cases

• For highly symptomatic or recurrent ulcers, consider systemic corticosteroids:
  • High-dose pulse 30-60 mg or 1 mg/kg oral prednisone/prednisolone for 1 week followed by dose tapering over the second week 2, 1
• For severe refractory cases, consider:
  • Colchicine for recurrent aphthous stomatitis 4
  • Pentoxifylline 3
  • Thalidomide (most effective but limited by adverse effects) 4

Special Considerations

• Treat concurrent candidal infection with nystatin oral suspension or miconazole oral gel 1
• For patients with HIV infection, the same diagnostic and treatment approach can be used, but be alert for atypical presentations 5
• Investigate for underlying causes in recurrent aphthous stomatitis (RAS), including:
  • Gastrointestinal diseases (celiac disease, inflammatory bowel diseases) 4
  • Nutritional deficiencies (iron, folates) 4
  • Immune disorders (HIV infection, neutropenia) 4
  • Behçet's disease 4

Treatment Algorithm

1. Start with topical corticosteroids as first-line treatment 1, 2
2. Provide appropriate pain management based on severity 2
3. If no improvement after 1-2 weeks, escalate to second-line treatments 1
4. For severe or refractory cases, consider systemic therapy 2, 1, 4
5. Investigate and address any underlying causes for recurrent cases 4