What are the treatment options for managing aphthous ulcers?

Management of Aphthous Ulcers

Start with topical corticosteroids as first-line therapy, combined with topical anesthetics for pain control, and escalate to systemic therapies only for severe or refractory cases. 1, 2, 3

First-Line Topical Therapy

Topical Corticosteroids (Primary Treatment)

For localized ulcers:

• Apply clobetasol 0.05% ointment mixed in 50% Orabase twice daily to dried mucosa 1, 2
• Alternatively, use triamcinolone acetonide 0.1% paste applied directly to dried ulcer 2-4 times daily 1, 4

For multiple or widespread ulcers:

• Use betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water as rinse-and-spit solution 2-4 times daily 1, 2, 3
• Alternatively, dexamethasone mouth rinse (0.1 mg/mL) for difficult-to-reach areas 1

Pain Management (Essential Adjunct)

• Apply viscous lidocaine 2% topically 3-4 times daily, particularly before meals 1, 2, 3
• Use benzydamine hydrochloride rinse or spray every 3 hours, especially before eating 1, 2
• Consider amlexanox 5% oral paste for combined anti-inflammatory and analgesic effects 1, 5, 4

Barrier Protection and Oral Hygiene

• Apply mucoprotectant mouthwashes (Gelclair or Gengigel) three times daily to protect ulcer surface 1, 2, 3
• Rinse with 0.2% chlorhexidine digluconate mouthwash twice daily to prevent secondary infection 1, 2, 3
• Clean mouth daily with warm saline mouthwashes to reduce bacterial colonization 1, 2

Second-Line Therapy for Refractory Cases

When topical therapy fails after 1-2 weeks:

Intralesional Steroids

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

Alternative Topical Immunomodulator

• Apply tacrolimus 0.1% ointment twice daily for 4 weeks as alternative to triamcinolone 1, 2

Systemic Therapy for Severe or Highly Symptomatic Cases

Reserve for patients with frequent recurrences or severe symptoms affecting quality of life:

Systemic Corticosteroids

• Prednisone/prednisolone 30-60 mg (or 1 mg/kg) for 1 week, then taper over the second week 1, 2, 3
• In children: dose at 1-1.5 mg/kg/day up to maximum 60 mg 1

First-Line Systemic Steroid-Sparing Agent

• Colchicine is the preferred first-line systemic therapy for recurrent aphthous stomatitis, particularly effective when associated with erythema nodosum or genital ulcers 1, 2, 3, 6, 7

Additional Systemic Options for Resistant Cases

• Consider azathioprine, interferon-alpha, TNF-alpha inhibitors, or apremilast for cases refractory to colchicine 1, 2, 3
• Thalidomide is the most effective treatment but use is limited by frequent adverse effects 6

Preventive Measures

• Avoid hard, acidic, salty foods and toothpastes containing sodium lauryl sulfate 7
• Eliminate alcohol and carbonated drinks 7
• Screen for nutritional deficiencies (iron, folates, vitamin B12) and underlying conditions (celiac disease, inflammatory bowel disease) 6, 7

Critical Decision Points

Refer to specialist if:

• Ulcers persist beyond 2 weeks despite treatment 1
• Ulcers do not respond to 1-2 weeks of appropriate therapy 1
• Solitary chronic ulcer present (requires biopsy to exclude squamous cell carcinoma) 6

Perform biopsy when:

• Any ulcer lasting over 2 weeks without response to treatment 1
• Solitary chronic ulcer to rule out malignancy 6

Common Pitfalls to Avoid

• Do not prematurely taper corticosteroids before disease control is established 1
• Do not use phenytoin as it is less effective than triamcinolone acetonide (86.7% vs 53.3% response rate) 8
• Do not delay specialist referral for persistent or atypical ulcers 1
• Do not forget to exclude underlying systemic conditions in patients with recurrent aphthous stomatitis 2, 6, 7