What is the treatment for aphthous ulcers?

Treatment of Aphthous Ulcers

Start with high-potency topical corticosteroids as first-line therapy, specifically betamethasone sodium phosphate 0.5 mg dissolved in 10 mL of water as a rinse-and-spit solution one to four times daily. 1

First-Line Treatment Approach

Topical Corticosteroids (Primary Therapy)

The American College of Physicians establishes topical corticosteroids as the cornerstone of aphthous ulcer management. 1, 2 Your specific options include:

• Betamethasone sodium phosphate 0.5 mg in 10 mL water: Use as a 2-3 minute rinse-and-spit solution one to four times daily for accessible lesions 1
• Dexamethasone mouth rinse (0.1 mg/ml): Preferred for multiple lesions or difficult-to-reach ulcerations 1
• Clobetasol 0.05% ointment: Mix in 50% Orabase and apply twice weekly to localized lesions on dried mucosa 1
• Fluticasone propionate nasules: Dilute in 10 mL of water twice daily 1

Pain Management (Concurrent with Corticosteroids)

Layer pain control based on severity:

• Mild pain: Bland non-alcoholic sodium bicarbonate mouthwash four to six times daily, increasing to hourly if needed 1
• Moderate pain: Amlexanox 5% oral paste (topical NSAID) 1
• Severe pain: Viscous lidocaine 2% anesthetic mouthwash 1, 2
• Adjunctive: Coating agents for symptom relief 1
• Systemic analgesics: As needed for breakthrough pain 1

Supportive Measures

• Avoid sodium lauryl sulfate-containing toothpastes, hard/acidic/salty foods, alcohol, and carbonated drinks 3
• For patients with oral dryness: sugarless gum/candy or salivary substitutes 1

Second-Line Treatment (No Improvement After 1-2 Weeks)

If topical corticosteroids fail after 1-2 weeks, escalate therapy: 1

• Tacrolimus 0.1% ointment: Apply twice daily for 4 weeks for recalcitrant ulcers 1
• Intralesional triamcinolone: Weekly injections (total dose 28 mg) combined with topical clobetasol gel or ointment (0.05%) 1, 2

Systemic Therapy for Severe/Refractory Cases

For highly symptomatic, recurrent, or treatment-resistant ulcers:

• Oral prednisone/prednisolone: High-dose pulse 30-60 mg or 1 mg/kg for 1 week, followed by dose tapering over the second week 1, 2
• For recurrent aphthous stomatitis (≥4 episodes/year): Colchicine is suitable for most cases 4, 3
• Refractory cases: Consider azathioprine, interferon-alpha, or TNF-alpha inhibitors 2
• Most effective but limited by side effects: Thalidomide (reserved for severe refractory cases) 4

Critical Pitfalls to Avoid

• Red flag for referral: Any oral ulcer lasting >2 weeks or not responding to 1-2 weeks of treatment requires specialist referral and biopsy to rule out malignancy 2
• Concurrent infection: Treat candidal superinfection with nystatin oral suspension or miconazole oral gel 1
• Antiseptic agents: Chlorhexidine digluconate 0.2% can promote healing and prevent infection 2, 3

Treatment Algorithm Summary

1. Initiate: Topical corticosteroids (betamethasone or dexamethasone rinse) + appropriate pain management 1
2. Reassess at 1-2 weeks: If no improvement, advance to tacrolimus or intralesional steroids 1
3. Severe/recurrent cases: Add systemic corticosteroids or colchicine 1, 2, 4
4. Persistent beyond 2 weeks: Refer for biopsy to exclude malignancy 2