What is the treatment for recurrent oral ulcers?

Treatment of Recurrent Oral Ulcers

Start with topical corticosteroids as first-line therapy for recurrent oral ulcers, progressing to systemic treatments only for refractory cases that fail to respond to topical measures. 1

Initial Topical Treatment Approach

The management of recurrent oral ulcers should follow a stepwise algorithm based on severity and response to treatment:

First-Line Topical Therapies

For localized, accessible ulcers:

• Apply clobetasol gel or ointment 0.05% directly to dried ulcers 2-4 times daily 1
• Alternatively, use triamcinolone acetonide 0.1% paste applied to dried ulcer 2-4 times daily 1

For widespread or difficult-to-reach ulcers:

• Use dexamethasone mouth rinse (0.1 mg/ml) as a rinse-and-spit preparation 1
• Alternatively, betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water used as rinse-and-spit 2-4 times daily 1, 2

Adjunctive Symptomatic Measures

Pain control is essential and should be implemented alongside corticosteroids:

• Apply viscous lidocaine 2% before meals for topical anesthesia 1, 2
• Use benzydamine hydrochloride rinse or spray every 3 hours, particularly before eating 1, 2
• Consider amlexanox 5% oral paste for severe pain 1

Oral hygiene and barrier protection:

• Clean mouth daily with warm saline mouthwashes or sodium bicarbonate rinses 4-6 times daily 1, 2
• Use antiseptic oral rinses twice daily (0.2% chlorhexidine digluconate or 1.5% hydrogen peroxide) 1
• Apply mucoprotectant mouthwashes (Gelclair or Gengigel) three times daily 1, 2

Second-Line Treatment for Refractory Cases

When topical therapy fails after 1-2 weeks, escalate treatment systematically:

Intralesional Corticosteroids

• Administer triamcinolone injections weekly (total dose 28 mg) for persistent localized ulcers 1, 2

Systemic Corticosteroids

• For highly symptomatic or recurrent ulcers: prednisone/prednisolone 30-60 mg or 1 mg/kg for 1 week, then taper over the second week 1, 2
• This approach is particularly important for severe cases affecting quality of life 3

Alternative Systemic Agents

• Colchicine should be the preferred first-line systemic therapy, especially when erythema nodosum or genital ulcers coexist 3, 1, 2
• Tacrolimus 0.1% ointment applied twice daily for 4 weeks can be effective for recalcitrant cases 1, 2

Third-Line Immunosuppressive Therapy

For resistant cases that fail conventional treatments:

• Azathioprine 2.5 mg/kg/day is effective in preventing mucocutaneous lesions 3, 1
• Interferon-alpha has shown significant improvement in mucocutaneous lesions in RCTs 3
• TNF-alpha antagonists (such as etanercept) should be reserved for the most resistant cases 3, 1
• Apremilast may be considered in selected cases 1

Important Clinical Pitfalls to Avoid

Premature tapering of corticosteroids before disease control is established leads to treatment failure 1

Distinguish recurrent aphthous stomatitis from herpes simplex virus infection:

• Herpes typically affects keratinized mucosa (lips, hard palate, gingiva) and requires antiviral therapy 2
• Aphthous ulcers occur on non-keratinized mucosa (buccal mucosa, tongue, soft palate) 2

Refer to specialist for:

• Ulcers lasting more than 2 weeks 1
• Ulcers not responding to 1-2 weeks of treatment 1
• Suspicion of malignancy or systemic disease 1

Special Considerations for Behçet's Disease

If Behçet's disease is diagnosed, treatment should be tailored to quality of life impact:

• Start with topical corticosteroids and colchicine 3
• Sucralfate suspension has RCT evidence for oral and genital ulcers 3
• Progress to azathioprine, interferon-alpha, or TNF-alpha antagonists for resistant mucocutaneous findings 3
• Avoid ciclosporine A in patients with neurological involvement due to neurotoxicity risk 3

Supportive Lifestyle Modifications

Dietary and environmental modifications reduce ulcer frequency:

• Avoid hard, acidic, salty foods, alcohol, and carbonated drinks 4
• Avoid toothpastes containing sodium lauryl sulfate 4
• Consume soft, moist, non-irritating foods 1
• Use sugarless chewing gum or salivary substitutes for dry mouth 1