What is the management of aphthous ulcers in children?

Management of Aphthous Ulcers in Children

Start with topical corticosteroids as first-line therapy, combined with topical anesthetics for pain control and supportive oral hygiene measures. 1

First-Line Topical Treatment

Topical Corticosteroids

• Apply clobetasol gel or ointment (0.05%) for localized, accessible ulcers 1
• For widespread or difficult-to-reach ulcers, use dexamethasone mouth rinse (0.1 mg/ml) 1
• Alternatively, betamethasone sodium phosphate 0.5 mg in 10 ml water as a rinse-and-spit preparation four times daily 1
• In infants specifically, clobetasol propionate 0.05% cream or ointment can be applied topically to affected areas in very small amounts 2

Pain Control

• Use viscous lidocaine 2% mouthwash before meals 1
• Apply benzydamine hydrochloride rinse or spray every 3 hours, particularly before eating 1
• For severe pain, consider topical NSAIDs such as amlexanox 5% oral paste 1
• In infants, oral acetaminophen is recommended for pain relief 2
• Topical 2.5% lidocaine ointment can be cautiously applied in infants, but use sparingly to avoid accidental ingestion 2

Barrier Protection

• Apply white soft paraffin ointment to the lips every 2 hours 1, 2
• Use mucoprotectant mouthwashes (e.g., Gelclair) three times daily 1
• Apply barrier dressings when practical, though these may be difficult to maintain in the oral cavity of an infant 2

Oral Hygiene and Supportive Care

• Clean the mouth daily with warm saline mouthwashes 1, 2
• For infants, parents can use a clean finger wrapped in gauze soaked in warm saline to gently clean the affected areas 2
• Use antiseptic oral rinses twice daily (e.g., 1.5% hydrogen peroxide or 0.2% chlorhexidine digluconate) 1
• Ensure adequate hydration in infants, as painful ulcers may cause the baby to resist drinking 2

Second-Line Management for Refractory Cases

Intralesional and Systemic Steroids

• For ulcers that don't respond to topical therapy after 1-2 weeks, consider intralesional steroid injections (triamcinolone weekly, total dose 28 mg) 1
• 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
• Avoid systemic corticosteroids for simple aphthous ulcers in infants unless absolutely necessary 2

Systemic Therapy for Recurrent Aphthous Stomatitis

• For recurrent aphthous stomatitis (≥4 episodes per year), try colchicine as first-line systemic therapy, especially if erythema nodosum or genital ulcers are present 1, 3
• Consider azathioprine, interferon-alpha, TNF-alpha inhibitors, or apremilast in selected cases 1
• Thalidomide is the most effective treatment but its use is limited by frequent adverse effects 3

When to Refer or Investigate Further

Red Flags Requiring Specialist Referral

• Refer to a specialist for oral ulcers lasting more than 2 weeks or not responding to 1-2 weeks of treatment 1
• Ulcers accompanied by symptoms of uveitis, genital ulcerations, conjunctivitis, arthritis, fever, or adenopathy require investigation for systemic disease 4
• Consider PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and adenopathy) in children with periodic oral ulcers coinciding with periodic fever 5

Diagnostic Workup for Persistent Ulcers

• Perform blood tests including full blood count, coagulation, fasting blood glucose level, HIV antibody, and syphilis serology examination before biopsy 1, 6
• Biopsy is indicated for ulcers lasting over 2 weeks or not responding to treatment 1
• Consider systemic causes including anemia, leukemia, neutropenia, iron and folate deficiencies, HIV infection, inflammatory bowel diseases, and Behçet's disease 6, 3

Common Pitfalls to Avoid

• Do not prematurely taper corticosteroids before disease control is established 1
• Overuse of topical anesthetics can lead to accidental ingestion and potential toxicity in infants 2
• Avoid petroleum-based products in young children due to risk of accidental oral ingestion 2
• Do not rely solely on topical treatments without establishing a definitive diagnosis for persistent ulcers 6
• Inadequate biopsy (small or superficial) may miss important diagnostic features 6