What is the treatment for aphthous ulcers in the oral mucosa of a child?

Treatment of Aphthous Ulcers in Children

For pediatric aphthous ulcers, begin with topical corticosteroids as first-line therapy combined with pain control measures, progressing to systemic treatments only for severe or refractory cases.

First-Line Topical Management

Pain Control

• Apply benzydamine hydrochloride oral rinse or spray every 2-4 hours, particularly before eating to reduce discomfort 1, 2, 3
• Use topical anesthetic preparations cautiously: viscous lidocaine 2% can be applied sparingly up to 3-4 times daily in children over 2 years 2, 4
• For children under 12 years using topical anesthetics, supervision is required to prevent accidental ingestion 5, 4
• Oral acetaminophen provides systemic pain relief and is recommended by the American Academy of Pediatrics 2

Topical Corticosteroids (Primary Treatment)

• For localized accessible ulcers: Apply clobetasol propionate 0.05% cream or ointment directly to dried ulcer 2-4 times daily 2, 3
• For multiple or widespread ulcers: Use betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water as a rinse-and-spit solution 2-4 times daily 1, 3
• Alternative option: Triamcinolone acetonide 0.1% paste applied directly to dried ulcer 2-4 times daily 3

Mucosal Protection

• Apply white soft paraffin ointment to lips every 2 hours throughout the acute phase 1, 2, 3
• Use mucoprotectant mouthwashes (e.g., Gelclair) three times daily to protect ulcerated surfaces 1, 3, 6

Oral Hygiene and Supportive Care

• Clean the mouth daily with warm saline mouthwashes or an oral sponge 1, 2, 3
• For young children, parents can use a clean finger wrapped in gauze soaked in warm saline 2
• Apply antiseptic oral rinses twice daily using either 1.5% hydrogen peroxide or 0.2% chlorhexidine digluconate (dilute by 50% to reduce soreness) 1, 3, 6

Feeding and Hydration

• Ensure adequate hydration, as painful ulcers may cause children to resist drinking 2
• Avoid spicy foods, hot foods/drinks, acidic foods, and other painful stimuli 6
• Offer favorite drinks for oral irrigation rather than standard mouthwashes to improve compliance 1

Second-Line Treatment for Refractory Cases

When to Escalate

If ulcers persist beyond 2 weeks or fail to respond to 1-2 weeks of topical treatment, consider:

• Intralesional triamcinolone injections weekly (total dose 28 mg) for persistent localized ulcers 3
• Systemic corticosteroids for highly symptomatic cases: prednisone/prednisolone at 1-1.5 mg/kg/day (maximum 40-60 mg) for 1 week, then taper over the second week 3
• Tacrolimus 0.1% ointment applied twice daily for 4 weeks as an alternative to topical corticosteroids 3, 6

For Recurrent Aphthous Stomatitis (≥4 episodes/year)

• Colchicine is recommended as first-line systemic therapy by the European League Against Rheumatism 3
• Consider azathioprine, interferon-alpha, or TNF-alpha inhibitors for resistant cases 3

Critical Pitfalls to Avoid

• Never overuse topical anesthetics in young children—accidental ingestion can lead to toxicity 2
• Avoid systemic corticosteroids for simple aphthous ulcers unless absolutely necessary; reserve for severe or recurrent cases 2
• Do not taper corticosteroids prematurely before disease control is established 3
• Stop treatment and consult a physician if symptoms do not improve in 7 days, or if irritation, pain, redness persists or worsens 5
• Refer to a specialist for ulcers lasting more than 2 weeks or not responding to initial treatment, as biopsy may be needed to exclude other diagnoses 3, 7

Special Considerations

• If candidal infection is suspected (slow healing, white coating), treat with nystatin oral suspension 100,000 units four times daily for 1 week or miconazole oral gel 5-10 mL four times daily 1, 6
• Consider underlying systemic conditions (celiac disease, inflammatory bowel disease, nutritional deficiencies, PFAPA syndrome) in children with recurrent ulcers 7, 8, 9
• Perform blood tests (complete blood count, nutritional studies) before escalating to systemic therapy 3