What is the treatment for aphthous ulcers, including dosages and duration?

Treatment of Aphthous Ulcers

Topical corticosteroids are the first-line treatment for aphthous ulcers, with 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 being the most effective option. 1

First-Line Treatments

Topical Corticosteroids

• Betamethasone sodium phosphate 0.5 mg dissolved in 10 mL of water as a rinse-and-spit solution 1-4 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

Topical Pain Relief

• Barrier preparations such as Gengigel mouth rinse/gel or Gelclair for pain control 1
• Topical anesthetics (e.g., lidocaine) should be tried first before escalating to corticosteroids 2
• Antiseptic agents like triclosan can provide symptomatic relief 2

Second-Line Treatments

For Recalcitrant Ulcers

• Tacrolimus 0.1% ointment applied twice daily for 4 weeks 1
• Intralesional triamcinolone (total dose 28 mg) in conjunction with topical clobetasol gel or ointment (0.05%) 1

Systemic Therapy for Severe Cases

For Highly Symptomatic or Recurrent Ulcers

• 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 1
• For severe recurrent cases: colchicine, pentoxifylline, or prednisolone may be considered 2
• Thalidomide is the most effective treatment for recurrent aphthous stomatitis but its use is limited by frequent adverse effects 3

Lifestyle Modifications

Dietary Adjustments

• Avoid hard, acidic, and salty foods 2
• Avoid toothpastes containing sodium lauryl sulfate 2
• Avoid alcohol and carbonated drinks 2

Treatment Algorithm

1. Mild to moderate single ulcers:

   • Start with topical anesthetics or antiseptics 2
   • If ineffective after 1-2 days, progress to topical corticosteroids 1, 2

2. Multiple or severe ulcers:

   • Begin with high-potency topical corticosteroids (betamethasone or clobetasol) 1
   • Add barrier preparations for pain relief 1

3. Recurrent or treatment-resistant ulcers:

   • Consider tacrolimus 0.1% ointment 1
   • For frequent recurrences, consider systemic therapy with colchicine or short-course systemic corticosteroids 1, 3

4. Concurrent conditions:

   • If candidal infection is present, add nystatin oral suspension or miconazole oral gel 1

Common Pitfalls and Caveats

• Failure to distinguish between aphthous ulcers and other oral ulcerative conditions can lead to inappropriate treatment 3, 4
• Systemic treatments should be reserved for severe, refractory cases due to potential side effects 2, 5
• Recurrent aphthous stomatitis may be associated with underlying conditions such as celiac disease, inflammatory bowel diseases, nutritional deficiencies, or immune disorders which should be investigated in persistent cases 3
• Treatment efficacy varies between individuals, and what works for one patient may not work for another 5
• Any solitary chronic oral ulcer that doesn't heal should be biopsied to rule out squamous cell carcinoma 3