What is the treatment for oral aphthous ulcers?

Treatment Prescription for Oral Aphthous Ulcers

Start with betamethasone sodium phosphate 0.5 mg dissolved in 10 mL of water as a rinse-and-spit solution, used 1-4 times daily, which represents the first-line treatment recommended by the British Journal of Dermatology. 1

First-Line Topical Corticosteroid Options

Choose one of the following based on ulcer location and severity:

• Betamethasone sodium phosphate 0.5 mg in 10 mL water: Rinse for 2-3 minutes and spit, 1-4 times daily 1, 2
• Fluticasone propionate nasules: Dilute in 10 mL water, use twice daily 1, 2
• Clobetasol 0.05% ointment mixed in 50% Orabase: Apply twice weekly to localized lesions on dried mucosa 1, 2

Pain Management (Add as Needed)

• Benzydamine hydrochloride oral rinse or spray: Every 3 hours, particularly before eating 2
• Viscous lidocaine 2%: Apply 3-4 times daily for severe pain 2
• Barrier preparations: Gengigel mouth rinse/gel or Gelclair for additional pain control 1, 2

Oral Hygiene Adjuncts

• Warm saline mouthwashes: Daily to reduce bacterial colonization 2
• Chlorhexidine digluconate 0.2% mouthwash: Twice daily 2
• Avoid sodium lauryl sulfate-containing toothpastes, hard/acidic/salty foods, alcohol, and carbonated drinks 3

Second-Line Treatment for Refractory Ulcers

If topical corticosteroids fail after 1-2 weeks:

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

Systemic Therapy for Severe or Recurrent Cases

Reserve for highly symptomatic ulcers or those unresponsive to topical treatment:

• Prednisone/prednisolone: 30-60 mg or 1 mg/kg daily for 1 week, then taper over the second week 1, 2
• Colchicine: Particularly effective for recurrent aphthous stomatitis, especially with erythema nodosum or genital ulcers 4, 2, 5
• Azathioprine, interferon-alpha, or TNF-alpha antagonists: Only for resistant cases 4, 2

Treatment of Concurrent Infections

If candidal infection is present (common with corticosteroid use):

• Nystatin oral suspension 100,000 units: Four times daily for 1 week 2
• Miconazole oral gel 5-10 mL: Hold in mouth after food, four times daily for 1 week 1, 2

Critical Pitfalls to Avoid

• Do not use topical anesthetics alone as primary therapy—they provide only symptomatic relief without addressing inflammation 1, 2
• Avoid premature tapering of systemic corticosteroids before disease control is established 2
• Screen for underlying systemic conditions in patients with recurrent aphthous stomatitis (celiac disease, inflammatory bowel disease, nutritional deficiencies, HIV) 2, 5
• Biopsy any solitary chronic ulcer that persists beyond 2-3 weeks to rule out squamous cell carcinoma 5

Treatment Algorithm Summary

1. Start with topical corticosteroids (betamethasone rinse or clobetasol ointment) 1, 2
2. Add pain management (benzydamine or lidocaine) as needed 2
3. Ensure proper oral hygiene with saline rinses and chlorhexidine 2
4. If no improvement in 1-2 weeks, advance to tacrolimus or intralesional triamcinolone 1, 2
5. For severe/recurrent cases, use systemic corticosteroids or colchicine 1, 2
6. Reserve immunosuppressives for truly refractory cases 4, 2