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: Topical Corticosteroids

The cornerstone of aphthous ulcer management is topical corticosteroid therapy, which reduces pain, accelerates healing, and restores normal oral function. 1, 2 You have several evidence-based options:

For widespread or multiple lesions:

• Betamethasone sodium phosphate 0.5 mg dissolved in 10 mL of water: use as a 2-3 minute rinse-and-spit solution one to four times daily 1
• Dexamethasone mouth rinse (0.1 mg/ml) for multiple lesions or difficult-to-reach ulcerations 1
• Fluticasone propionate nasules diluted in 10 mL of water twice daily 1

For localized lesions:

• Clobetasol 0.05% ointment mixed in 50% Orabase: apply twice weekly to dried mucosa 1
• Triamcinolone acetonide can also be used topically 3

Pain Management Strategy

Pain control should be implemented alongside corticosteroid therapy, with intensity matched to symptom severity:

For mild to moderate pain:

• Bland non-alcoholic, sodium bicarbonate containing mouthwash four to six times daily (increase to hourly if needed) 1
• Amlexanox 5% oral paste (topical NSAID) 1
• Coating agents 1

For severe pain:

• Viscous lidocaine 2% anesthetic mouthwash 1
• Systemic analgesics as needed 1

Supportive Care Measures

Address oral dryness if present:

• Sugarless chewing gum or candy 1
• Salivary substitutes or sialogogues 1

Avoid precipitating factors:

• Hard, acidic, and salty foods 4
• Toothpastes containing sodium lauryl sulfate 4
• Alcohol and carbonated drinks 4

Second-Line Treatment for Refractory Cases

If ulcers persist after 1-2 weeks of topical corticosteroid therapy, escalate treatment: 1

• Tacrolimus 0.1% ointment applied twice daily for 4 weeks 1
• Weekly intralesional triamcinolone (total dose 28 mg) combined with topical clobetasol gel or ointment (0.05%) 1

Systemic Therapy for Severe or Highly Recurrent Disease

For highly symptomatic or recurrent ulcers that fail topical therapy:

• High-dose oral prednisone/prednisolone 30-60 mg (or 1 mg/kg) for 1 week, followed by dose tapering over the second week 1
• Colchicine for recurrent aphthous stomatitis (particularly effective when associated with Behçet's disease) 5, 4
• Pentoxifylline as an alternative systemic option 4

Important caveat: Systemic corticosteroids should be reserved for severe cases of major aphthous ulcers that do not respond to topical agents. 2 The efficacy of systemic treatments beyond corticosteroids remains debated. 4

Special Considerations

Treat concurrent candidal infection if present:

• Nystatin oral suspension or miconazole oral gel 1

Rule out underlying systemic causes before initiating symptomatic treatment:

• Gastro-intestinal diseases (celiac disease, inflammatory bowel disease) 5
• Nutritional deficiencies (iron, folates, vitamin B12) 5, 3
• Immune disorders (HIV infection, neutropenia) 5
• Behçet's disease (characterized by recurrent bipolar aphthosis) 5

Common pitfall: Do not confuse aphthous ulcers with Vincent stomatitis (which requires metronidazole) or herpes simplex stomatitis (which requires acyclovir). 6 Every solitary chronic oral ulcer should be biopsied to rule out squamous cell carcinoma. 5

Treatment Algorithm Summary

1. Initiate topical corticosteroids (betamethasone or dexamethasone rinse for multiple lesions; clobetasol ointment for localized lesions) 1
2. Provide appropriate pain management based on severity (sodium bicarbonate mouthwash → topical NSAIDs → viscous lidocaine) 1
3. Reassess after 1-2 weeks: if no improvement, escalate to tacrolimus or intralesional triamcinolone 1
4. Consider systemic therapy (oral corticosteroids or colchicine) only for severe or refractory cases 1, 4

Key limitation: All current treatments are symptomatic and palliative—they relieve pain and reduce ulcer duration but do not alter recurrence or remission rates. 2, 3