What is the treatment for aphthous ulcers in children using steroid oral paste, such as triamcinolone acetonide (oral paste)?

Steroid Oral Paste for Aphthous Ulcers in Children

Topical corticosteroid pastes, particularly triamcinolone acetonide 0.1% in Orabase, are the recommended first-line treatment for aphthous ulcers in children, applied directly to dried lesions 2-4 times daily. 1, 2, 3

First-Line Topical Steroid Options

For pediatric aphthous ulcers, the following topical corticosteroid preparations are effective:

• Triamcinolone acetonide 0.1% paste (in Orabase): Apply directly to dried ulcer 2-4 times daily for localized lesions 4, 1, 5
• Clobetasol 0.05% ointment mixed in 50% Orabase: Apply twice weekly to dried mucosa for more severe localized ulcers 4, 1, 3
• Betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water: Use as rinse-and-spit solution 2-4 times daily for multiple or widespread ulcers 4, 1, 2, 3
• Dexamethasone mouth rinse (0.1 mg/mL): Alternative for difficult-to-reach or multiple ulcers 1, 2

Application Technique for Paste Formulations

The paste should be applied to a dried mucosal surface to ensure adherence and maximize contact time with the ulcer 4, 3. This is critical for efficacy, as moisture prevents proper adhesion of the paste.

Adjunctive Pain Management

Combine topical steroids with pain control measures:

• Benzydamine hydrochloride rinse or spray: Every 3 hours, particularly before meals 1, 3
• Viscous lidocaine 2%: Apply 3-4 times daily before eating for severe pain 1, 2, 3
• Barrier preparations (Gelclair, Gengigel): Three times daily for mucosal protection 4, 1, 3

Oral Hygiene Support

• Warm saline mouthwashes: Daily to reduce bacterial colonization 1, 3
• Chlorhexidine 0.2% mouthwash: Twice daily as antiseptic rinse 1, 2, 3

Evidence Supporting Triamcinolone Acetonide

Triamcinolone acetonide 0.1% paste demonstrated 86.7% positive response in treating aphthous ulcers in patients with Behçet's syndrome, significantly outperforming alternative treatments 5. A comparative study showed triamcinolone acetonide was equally effective to dexamethasone-based pastes for pain reduction and healing 6.

Second-Line Options for Refractory Cases

If topical steroids fail after 1-2 weeks:

• Intralesional triamcinolone injections: Weekly injections (total dose 28 mg) for persistent ulcers 4, 1, 3
• Systemic corticosteroids: Prednisone/prednisolone 1 mg/kg (maximum 40-60 mg) for 1 week with tapering over the second week for highly symptomatic cases 4, 1, 3
• Tacrolimus 0.1% ointment: Applied twice daily for 4 weeks as alternative to triamcinolone 4, 3

Critical Pitfalls to Avoid

• Do not prematurely taper corticosteroids before disease control is established 1, 3
• Refer to specialist if ulcers persist beyond 2 weeks or fail to respond to 1-2 weeks of treatment, as biopsy may be needed to exclude malignancy 1, 2
• Screen for underlying systemic conditions (celiac disease, inflammatory bowel disease, nutritional deficiencies) in children with recurrent aphthous stomatitis (≥4 episodes per year) 7, 8

Dosing Considerations for Children

For systemic corticosteroids when needed, pediatric dosing is 1-1.5 mg/kg/day up to maximum 60 mg for severe cases 4. However, topical therapy should always be exhausted first given the favorable safety profile in children 8.