What is the management of aphthous ulcers?

Management of Aphthous Ulcers

Begin with topical corticosteroids as first-line therapy for all aphthous ulcers, selecting the formulation based on ulcer location and extent, and escalate to systemic therapy only for refractory or severe recurrent cases. 1, 2, 3

First-Line Topical Therapy

Topical Corticosteroids (Primary Treatment)

For localized, accessible ulcers:

• Apply clobetasol 0.05% gel or ointment directly to dried ulcer 2-4 times daily 1, 2, 3
• Alternatively, use triamcinolone acetonide 0.1% paste applied to dried ulcer 2-4 times daily 1

For multiple or widespread ulcers:

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

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 (topical NSAID) for severe pain 1

Barrier Protection and Oral Hygiene

• Apply mucoprotectant mouthwashes (Gelclair or Gengigel) 3 times daily to protect ulcerated mucosa 1, 2, 3
• Rinse with warm saline mouthwashes daily to reduce bacterial colonization 1, 2
• Use 0.2% chlorhexidine digluconate mouthwash twice daily as antiseptic rinse 1, 2, 3
  • Important caveat: Chlorhexidine can paradoxically cause aphthous ulcers in rare cases and may cause tooth staining 4

Supportive Measures

• Apply white soft paraffin ointment to lips every 2 hours if lip involvement present 1
• Avoid crunchy, spicy, acidic foods and hot beverages 5, 1
• Discontinue toothpastes containing sodium lauryl sulfate 6
• Avoid alcohol and carbonated drinks 6

Second-Line Therapy for Refractory Cases

When topical therapy fails after 1-2 weeks:

Intralesional Steroids

• Inject triamcinolone weekly (total dose up to 28 mg) for persistent localized ulcers 1, 2, 3
• Can be combined with topical clobetasol for enhanced effect 2

Alternative Topical Agents

• Apply tacrolimus 0.1% ointment twice daily for 4 weeks for recalcitrant ulcers 1, 2

Systemic Therapy for Severe or Recurrent Cases

For recurrent aphthous stomatitis (≥4 episodes per year) or highly symptomatic cases:

First-Line Systemic Agent

• Colchicine is the preferred first-line systemic therapy, particularly effective when erythema nodosum or genital ulcers are also present 1, 2, 3, 7

Systemic Corticosteroids (For Severe Cases)

• Prednisone/prednisolone 30-60 mg (or 1 mg/kg) for 1 week, then taper over the second week 5, 1, 2, 3
• Critical pitfall: Do not taper corticosteroids prematurely before disease control is established 1

Third-Line Immunosuppressive Agents (Resistant Cases)

• Consider azathioprine, interferon-alpha, TNF-alpha inhibitors, or apremilast for cases resistant to colchicine and corticosteroids 5, 1, 2, 3
• Thalidomide is highly effective but reserved as last resort due to toxicity profile 8, 7, 9

When to Refer or Investigate Further

Refer to specialist if:

• Ulcers persist >2 weeks despite treatment 1, 3
• No response after 1-2 weeks of appropriate therapy 1
• Biopsy is mandatory for ulcers lasting >2 weeks to rule out malignancy 1, 3

Investigate for underlying systemic conditions:

• Obtain complete blood count, nutritional studies (iron, folate, B12), celiac serology, and HIV testing if recurrent 1, 7, 10
• Consider inflammatory bowel disease, Behçet's disease, or immunodeficiency in recurrent cases 7, 10, 6

Treatment Algorithm Summary

1. Start with topical corticosteroids (clobetasol for localized, betamethasone rinse for widespread) + pain control (lidocaine, benzydamine) + barrier agents 1, 2, 3
2. Add oral hygiene measures (saline rinses, chlorhexidine) and dietary modifications 1, 2
3. If no improvement in 1-2 weeks: Add intralesional triamcinolone or tacrolimus ointment 1, 2
4. For recurrent cases (≥4/year): Start colchicine as systemic therapy 1, 2, 3
5. For severe refractory cases: Short course of systemic corticosteroids with proper taper 5, 1, 2
6. For resistant cases: Consider immunosuppressive agents (azathioprine, biologics) 1, 2, 3

Key pitfall to avoid: The evidence from diabetic foot ulcer management 5 is not applicable to oral aphthous ulcers and should be disregarded in this context.