What are the treatment options for aphthous ulcers?

Treatment of Aphthous Ulcers

Topical treatments should be used as first-line therapy for aphthous ulcers, including steroids, anesthetics, and barrier agents, followed by systemic therapies for refractory cases. 1

First-Line Topical Treatments

Topical Corticosteroids

• Apply topical steroids as primary therapy for accessible lesions 1, 2
• Options include:
  • Betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water as a rinse-and-spit solution four times daily 1, 2
  • Dexamethasone mouth rinse (0.1 mg/ml) for widespread or difficult-to-reach ulcers 1
  • Clobetasol 0.05% ointment mixed in Orabase applied to dried mucosa for localized ulcers 1, 2

Pain Management

• Topical anesthetic preparations are effective for pain relief and may be more effective than corticosteroids 3
• Apply viscous lidocaine 2% before meals, 3-4 times daily 1, 4
  • Do not use more than 3-4 times daily 4
  • Avoid contact with eyes and mucous membranes 4
  • Discontinue if irritation develops or symptoms persist for more than 7 days 4
• Benzydamine hydrochloride rinse or spray every 3 hours, particularly before eating 1, 2

Barrier Agents and Oral Hygiene

• Apply mucoprotectant mouthwashes (e.g., Gelclair) three times daily 1
• Clean the mouth daily with warm saline mouthwashes 1, 2
• Use antiseptic oral rinses twice daily (e.g., 0.2% chlorhexidine digluconate) 1, 2

Second-Line Treatments for Refractory Cases

Intralesional and Systemic Steroids

• For ulcers that don't respond to topical therapy, consider intralesional steroid injections (triamcinolone weekly) 1, 2
• Consider systemic corticosteroids for highly symptomatic or recurrent ulcers:
  • Prednisone/prednisolone 30-60 mg or 1 mg/kg for 1 week with tapering over the second week 1, 2
  • Avoid premature tapering before disease control is established 1

Other Systemic Therapies

• For recurrent aphthous stomatitis, try colchicine as first-line systemic therapy 1, 5
• Consider azathioprine, interferon-alpha, or TNF-alpha inhibitors for resistant cases 1, 2

Special Considerations

Nutritional Support

• Consider protein or amino acid supplementation to promote healing 6
• Evaluate for and correct nutritional deficiencies (iron, folates) that may contribute to recurrent ulcers 5

When to Refer

• Refer patients to a specialist for oral ulcers lasting more than 2 weeks or not responding to 1-2 weeks of treatment 1
• Biopsy is indicated for ulcers lasting over 2 weeks to rule out malignancy 1, 5

Associated Conditions

• Consider underlying systemic conditions in patients with recurrent aphthous ulcers:
  • Gastrointestinal diseases (celiac disease, inflammatory bowel diseases) 5
  • Immune disorders (HIV infection, neutropenia) 5, 7
  • Behçet's disease (characterized by recurrent bipolar aphthosis) 5

Clinical Classification and Approach

• Aphthous ulcers are classified into three types 5, 8:
  • Minor aphthous ulcers (most common, 80-90% of cases)
  • Major aphthous ulcers
  • Herpetiform aphthous ulcers
• Treatment should be tailored based on:
  • Frequency of ulcers
  • Intensity of pain
  • Responsiveness to treatment 9

Common Pitfalls to Avoid

• Proper diagnosis is essential before initiating treatment 2
• Avoid using chemical agents or plasters to remove callus or corns 6
• Do not bandage or apply local heat to areas treated with topical medications 4
• Discontinue use and consult a doctor if condition worsens, irritation develops, or symptoms persist for more than 7 days 4