What is the treatment for aphthous ulcers?

Treatment of Aphthous Ulcers

The most effective first-line treatment for aphthous ulcers is high-potency topical corticosteroids, such as betamethasone sodium phosphate 0.5 mg dissolved in 10 mL of water as a rinse-and-spit solution one to four times daily. 1

First-Line Treatments

• Apply high-potency topical corticosteroids as the primary treatment, with several effective options:
  • 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 1

Pain Management

• Use bland non-alcoholic, sodium bicarbonate containing mouthwash four to six times daily (can increase to once per hour if needed) 1
• Apply topical NSAIDs such as amlexanox 5% oral paste for moderate pain 1
• Use anesthetic mouthwashes like viscous lidocaine 2% for more severe pain 1
• Apply coating agents to protect the ulcer surface and reduce pain 1
• Consider systemic analgesics as needed for significant pain 1
• Avoid hard, acidic, salty foods, toothpastes containing sodium lauryl sulfate, alcohol, and carbonated drinks as they may exacerbate pain 2

Second-Line Treatments for Recalcitrant Ulcers

• Apply tacrolimus 0.1% ointment twice daily for 4 weeks 1
• Consider weekly intralesional triamcinolone (total dose 28 mg) in conjunction with topical clobetasol gel or ointment (0.05%) for ulcers that don't respond to topical treatment 1

Systemic Therapy for Severe or Refractory Cases

• High-dose pulse oral prednisone/prednisolone (30-60 mg or 1 mg/kg) for 1 week followed by dose tapering over the second week for highly symptomatic or recurrent ulcers 1
• For severe recurrent aphthous stomatitis (RAS), defined as oral aphthous ulcers occurring at least 4 times per year, colchicine may be considered 3
• In particularly severe or refractory cases, especially those associated with Behçet's disease, immunosuppressive agents may be necessary 2

Special Considerations

• Treat concurrent candidal infections with nystatin oral suspension or miconazole oral gel 1
• For patients with oral dryness, recommend sugarless chewing gum or candy, salivary substitutes or sialogogues 1
• Consider herbal treatments containing glycyrrhiza (licorice) extract, which has been shown to reduce lesion duration, size, and pain 4
• Any solitary chronic ulcer that doesn't heal should be biopsied to rule out squamous cell carcinoma 3
• Investigate for underlying causes in recurrent cases, including gastrointestinal diseases (celiac disease, inflammatory bowel diseases), nutritional deficiencies (iron, folates), or immune disorders (HIV infection) 3

Treatment Algorithm

1. Start with topical corticosteroids as first-line treatment
2. Provide appropriate pain management based on severity
3. If no improvement after 1-2 weeks, escalate to second-line treatments
4. Consider systemic therapy only for severe or refractory cases 1

Common Pitfalls and Caveats

• Failure to distinguish aphthous ulcers from other oral lesions can lead to inappropriate treatment 3
• Systemic corticosteroids should be reserved for severe cases due to potential side effects 5
• In HIV-infected patients, be alert for ulcers with uncommon causes or atypical appearances that may mimic aphthous ulcers 5
• Most OTC preparations only manage symptoms rather than altering the course of the condition, with exceptions including cyanoacrylate products and patches containing glycyrrhiza extract 4