What is the treatment for recurrent oral ulceration?

Treatment for Recurrent Oral Ulceration

For recurrent oral ulceration, topical corticosteroids should be used as first-line therapy, followed by systemic treatments for refractory cases based on the underlying cause and severity. 1

First-Line Topical Treatments

• Apply topical steroids as primary therapy for accessible oral ulcers:

  • For localized ulcers: clobetasol gel/ointment (0.05%) mixed with equal parts Orabase applied directly to dried mucosa 1, 2
  • For widespread or difficult-to-reach ulcers: dexamethasone mouth rinse (0.1 mg/ml) or betamethasone sodium phosphate 0.5 mg in 10 ml water as a rinse-and-spit preparation four times daily 1, 3

• Manage pain with:

  • Topical anesthetic mouthwashes (viscous lidocaine 2%) before meals 1, 2
  • Benzydamine hydrochloride rinse or spray every 3 hours, particularly before eating 1, 3
  • Mucoprotectant mouthwashes (e.g., Gelclair) three times daily to form a protective coating 1, 3

• Implement oral hygiene measures:

  • Clean mouth daily with warm saline mouthwashes 1, 3
  • Use antiseptic oral rinses twice daily (e.g., 0.2% chlorhexidine digluconate) 1, 3
  • Apply white soft paraffin ointment to affected lips every 2 hours 1, 3

Second-Line Treatments for Refractory Cases

• For ulcers that don't respond to topical therapy, consider:

  • Intralesional steroid injections (triamcinolone weekly, total dose 28 mg) 1, 2
  • Tacrolimus 0.1% ointment applied twice daily for 4 weeks 2, 3

• For highly symptomatic or recurrent ulcers, consider systemic treatments:

  • 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 for recurrent aphthous stomatitis, especially effective for erythema nodosum or genital ulcers 1, 4

• For resistant cases, consider:

  • Azathioprine 4, 1
  • Interferon-alpha 4, 1
  • TNF-alpha antagonists 4, 1
  • Thalidomide (with caution due to teratogenicity and risk of peripheral neuropathy) 4

Treatment for Secondary Infections

• If candidal infection is suspected, treat with:
  • Nystatin oral suspension 100,000 units four times daily for 1 week 3
  • Miconazole oral gel 5-10 mL held in the mouth after food four times daily for 1 week 3

Special Considerations for Specific Conditions

• For Behçet's disease with oral ulcers:

  • Start with topical steroids and colchicine 4, 1
  • Progress to immunosuppressives for refractory cases 4
  • Avoid ciclosporine A in patients with neurological involvement due to potential neurotoxicity 4

• For Stevens-Johnson syndrome/toxic epidermal necrolysis with oral involvement:

  • Implement aggressive topical measures including steroids, anesthetics, and antiseptics 1
  • Consider systemic therapy for severe cases 1

Common Pitfalls to Avoid

• Premature tapering of corticosteroids before disease control is established 1, 3
• Failure to identify and address underlying systemic conditions in patients with recurrent aphthous ulcers 3
• Delay in referring patients with ulcers lasting more than 2 weeks or not responding to 1-2 weeks of treatment to a specialist 1

Treatment Algorithm

1. Initial Assessment: Determine severity, location, and pattern of ulceration
2. Mild to Moderate Cases: Begin with topical corticosteroids and pain management
3. If No Response After 1-2 Weeks: Add intralesional steroids or tacrolimus
4. For Severe or Recurrent Cases: Add systemic therapy (corticosteroids, colchicine)
5. For Resistant Cases: Consider immunomodulatory agents (azathioprine, TNF-alpha inhibitors)
6. Ongoing Management: Maintain oral hygiene and implement preventive measures to reduce recurrence