Management of Recurrent Pustular Oral Ulcers
Start with topical corticosteroids as first-line therapy, specifically clobetasol 0.05% gel or ointment for localized lesions or betamethasone sodium phosphate 0.5 mg in 10 mL water as a rinse-and-spit solution four times daily for widespread ulcers, combined with aggressive pain control using benzydamine hydrochloride rinse or viscous lidocaine 2% before meals. 1, 2
First-Line Topical Management
Corticosteroid Options
- Apply clobetasol 0.05% ointment directly to dried ulcers twice daily for localized lesions 1, 2, 3
- For multiple or widespread ulcers, use betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water as a 2-3 minute rinse-and-spit solution one to four times daily 1, 2, 3
- Alternatively, use triamcinolone acetonide 0.1% paste applied directly to dried ulcer 2-4 times daily 1
- Dexamethasone mouth rinse (0.1 mg/mL) or fluticasone propionate nasules diluted in 10 mL water twice daily are additional options 1, 2
Pain Control (Critical for Maintaining Oral Intake)
- Use benzydamine hydrochloride rinse or spray every 3 hours, particularly before eating 1, 3
- Apply viscous lidocaine 2% topically 3-4 times daily before meals for severe pain 1, 3
- Consider topical NSAIDs such as amlexanox 5% oral paste 1
- Apply barrier preparations like Gelclair or Gengigel mouth rinse/gel three times daily for mucosal protection 1, 2
Supportive Oral Hygiene
- Clean the mouth daily with warm saline mouthwashes to reduce bacterial colonization 1, 3
- Use antiseptic oral rinses such as 0.2% chlorhexidine digluconate mouthwash twice daily 1, 3
- Apply white soft paraffin ointment to lips every 2 hours if affected 1
Second-Line Management for Refractory Cases
When Topical Therapy Fails After 1-2 Weeks
- Consider intralesional triamcinolone injections weekly (total dose 28 mg) in conjunction with topical clobetasol 1, 2, 3
- Tacrolimus 0.1% ointment applied twice daily for 4 weeks is an alternative to triamcinolone 1, 2
Systemic Therapy for Highly Symptomatic or Recurrent Ulcers
- Use systemic corticosteroids: prednisone/prednisolone 30-60 mg or 1 mg/kg for 1 week followed by dose tapering over the second week 1, 2, 3
- For recurrent aphthous stomatitis with frequent episodes, colchicine is recommended as first-line systemic therapy, especially if concurrent erythema nodosum or genital ulcers are present 1
- Consider azathioprine, interferon-alpha, TNF-alpha inhibitors, or apremilast in selected refractory cases 1
Critical Diagnostic Considerations
When to Escalate or Refer
- Refer to a specialist if ulcers persist beyond 2 weeks or do not respond to 1-2 weeks of treatment, as biopsy is indicated to exclude malignancy 1, 3
- Perform blood tests including full blood count, coagulation studies, fasting blood glucose, HIV antibody, and syphilis serology before biopsy 1
Underlying Causes to Investigate
The term "pustular" is unusual for typical aphthous ulcers, which typically present as ulcers with erythematous haloes and yellow/gray floors rather than true pustules 4, 5. Consider:
- Medication-related ulceration (particularly NSAIDs) 3, 4
- Infectious causes (bacterial, viral, fungal) 4
- Autoimmune/systemic diseases including Behçet's syndrome 1, 4
- Nutritional deficiencies (iron, folate, B12) 4, 6
- Gastrointestinal diseases (celiac disease, inflammatory bowel disease) 4
Common Pitfalls to Avoid
- Do not prematurely taper corticosteroids before disease control is established 1, 3
- Avoid hard, acidic, salty foods and toothpastes containing sodium lauryl sulfate 7
- Avoid alcohol and carbonated drinks 7
- Treat concurrent candidal infection with nystatin oral suspension or miconazole oral gel before or during corticosteroid therapy 2
- Do not restart NSAIDs if they are the suspected cause without considering risk-benefit ratio 3
Special Considerations for Behçet's Syndrome
If recurrent oral and genital ulcers suggest Behçet's syndrome: