What is the treatment for aphthous ulcers (canker sores)?

Treatment of Canker Sores (Aphthous Ulcers)

Start with topical corticosteroids as first-line therapy for canker sores, combined with topical anesthetics for pain relief, and escalate to systemic therapies only for severe or recurrent cases that fail initial treatment. 1, 2

First-Line Topical Therapy

Topical Corticosteroids (Primary Treatment)

• Apply clobetasol 0.05% gel or ointment directly to dried ulcers for localized lesions 1, 3
• For widespread or hard-to-reach 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
• Alternatively, use dexamethasone mouth rinse (0.1 mg/mL) for multiple ulcers 1, 2
• For more severe localized ulcers, apply clobetasol 0.05% ointment mixed in 50% Orabase twice weekly to dried mucosa 3

Pain Management (Essential Adjunct)

• Use viscous lidocaine 2% before meals to enable eating 1, 2
• Apply benzydamine hydrochloride rinse or spray every 3 hours, particularly before eating 1, 3
• Consider amlexanox 5% oral paste (topical NSAID) for severe pain 1
• Use mucoprotectant mouthwashes (Gelclair) three times daily to create a protective barrier 1, 3

Oral Hygiene Measures

• Clean the mouth daily with warm saline mouthwashes to reduce bacterial colonization 1, 3
• Use antiseptic oral rinses twice daily (0.2% chlorhexidine digluconate or 1.5% hydrogen peroxide) 1, 3

Second-Line Treatment for Refractory Cases

When to Escalate

Escalate therapy when ulcers persist beyond 2 weeks or fail to respond to 1-2 weeks of topical treatment 1, 2

Intralesional Therapy

• Administer intralesional triamcinolone injections weekly (total dose 28 mg) for persistent localized ulcers 1, 3

Systemic Corticosteroids

• Use prednisone/prednisolone 30-60 mg (or 1 mg/kg) for 1 week with tapering over the second week for highly symptomatic or recurrent ulcers 1, 2, 3
• This approach is reserved for severe cases that don't respond to topical agents 4

Treatment for Recurrent Aphthous Stomatitis (≥4 Episodes/Year)

First-Line Systemic Therapy

• Start colchicine as first-line systemic therapy, especially effective when erythema nodosum or genital ulcers are present 1, 2, 3
• Colchicine combined with topical treatments constitutes suitable management for most recurrent cases 5

Alternative Systemic Options for Resistant Cases

• Consider azathioprine, interferon-alpha, TNF-alpha inhibitors, or apremilast for cases resistant to colchicine 1, 2, 3
• Thalidomide is the most effective treatment but should be used only as an alternative to oral corticosteroids due to frequent adverse effects and toxicity 5, 4

Critical Pitfalls to Avoid

• Never taper corticosteroids prematurely before disease control is established 1
• Avoid sodium lauryl sulfate-containing toothpastes, as well as hard, acidic, salty foods, alcohol, and carbonated drinks 6
• Refer to a specialist for ulcers lasting more than 2 weeks or not responding to treatment to rule out malignancy 1, 2
• Perform biopsy for any solitary chronic ulcer to exclude squamous cell carcinoma 5

Special Considerations

Nutritional Support

• Consider protein or amino acid supplementation to promote healing 2

Underlying Conditions to Evaluate

• Screen for celiac disease, inflammatory bowel disease, nutritional deficiencies (iron, folates), HIV infection, and Behçet's disease in patients with recurrent ulcers 5, 6
• Perform blood tests including full blood count, coagulation studies, fasting glucose, HIV antibody, and syphilis serology before biopsy 1

Treatment Algorithm Summary

1. Start with topical corticosteroids + topical anesthetics + oral hygiene measures 1, 2
2. If no response after 1-2 weeks, add intralesional steroids or switch to systemic corticosteroids 1, 3
3. For recurrent cases (≥4/year), initiate colchicine 1, 2
4. For refractory cases, escalate to immunosuppressive agents 1, 3