What is the treatment for oral and neck ulcers?

Treatment of Oral and Neck Ulcers

Begin with basic oral care protocols and sodium bicarbonate mouthwashes, escalate to topical corticosteroids for persistent ulcers, and obtain urgent diagnostic workup including biopsy for any ulcer lasting beyond 2 weeks to exclude malignancy and systemic disease. 1, 2

Immediate Symptomatic Management

First-Line Topical Therapy

• Implement basic oral care protocols immediately for all patients with oral ulcers, including elimination of trauma sources (sharp edges, ill-fitting prostheses) and avoidance of hot foods, hard/sharp/spicy foods 1
• Prescribe sodium bicarbonate-containing mouthwash (non-alcoholic) 4-6 times daily initially, increasing frequency up to hourly if needed for active treatment 1
• Apply topical anesthetics before meals: viscous lidocaine 2% (15 mL per application) or benzydamine hydrochloride rinse/spray every 3 hours, particularly before eating 1, 2
• Use coating agents and mucoprotectants such as Gelclair three times daily to protect ulcerated surfaces 2

Pain Management Algorithm

• For mild pain: Start with topical anesthetics (viscous lidocaine 2%) and coating agents 1
• For moderate pain: Add topical NSAID (amlexanox 5% oral paste); if NSAIDs not tolerated, use acetaminophen (paracetamol) as maintenance with immediate-release oral opioid or fast-acting fentanyl preparation (50 μg fentanyl nasal spray) for breakthrough pain before meals 1
• For severe persistent pain: Consider transdermal or intranasal routes of administration since oral complaints complicate oral drug administration 1

Topical Corticosteroid Escalation

• For localized, easily accessible ulcers: Apply clobetasol gel or ointment 0.05% directly to lesions 1, 2
• For multiple locations or difficult-to-reach ulcerations: Use dexamethasone mouth rinse 0.1 mg/mL 1
• For ulcers not responding to topical steroids: Administer intralesional triamcinolone injections weekly (total dose 28 mg) in conjunction with topical clobetasol 0.05% 1, 2

Critical Diagnostic Workup (Mandatory Before Escalation)

Laboratory Evaluation

• Obtain full blood count to detect leukemia, neutropenia, or anemia—widespread necrotic ulcers may indicate acute monocytic leukemia 2, 3
• Check fasting blood glucose—hyperglycemia predisposes to invasive fungal infection 2
• Test HIV antibody and syphilis serology to exclude infectious causes 2, 3
• Measure vitamin B12, folate, and iron levels to identify nutritional deficiencies 4
• For patients with high glucose and fever: Check 1-3-β-D-glucan and galactomannan levels, strongly suspecting invasive fungal infection 2

Microbiological Assessment

• Take oral and lip swabs if bacterial or candidal infection suspected 2
• Treat candidal infection with nystatin oral suspension 100,000 units four times daily for 1 week, or miconazole oral gel 5-10 mL held in mouth after food four times daily 2
• Consider HSV reactivation if slow healing occurs; treat with acyclovir if confirmed 2, 5

Biopsy Indications (Non-Negotiable)

• Any oral ulcer persisting beyond 2 weeks requires biopsy, especially without response to 1-2 weeks of symptomatic treatment 2, 3, 6
• Perform excisional biopsy for small lesions (≤3mm) to allow full histopathologic assessment 3
• Perform incisional biopsy from ulcer edge (including adjacent normal tissue) for larger lesions 3
• Obtain multiple biopsies when ulcers involve multiple sites with different morphological characteristics 3

Systemic Therapy for Refractory or Severe Cases

Corticosteroid Escalation

• For highly symptomatic ulcers or recurrent ulcers not responding to topical therapy: Prescribe prednisone/prednisolone 30-60 mg or 1 mg/kg orally for 1 week, followed by dose tapering over the second week 1, 2
• For esophageal lesions: Use systemic corticosteroids as initial therapy to bring symptoms under control quickly 1

Disease-Specific Systemic Treatment

• For Behçet's disease: Start colchicine as first-line systemic therapy, especially if erythema nodosum or genital ulcers present 2, 6, 7
• For severe refractory recurrent aphthous stomatitis: Consider azathioprine, interferon-alpha, TNF-alpha inhibitors, or apremilast after colchicine failure 2
• For oral tuberculosis: Initiate four-drug combination therapy with isoniazid, rifampicin, pyrazinamide, and ethambutol 2, 3
• For inflammatory bowel disease-associated ulcers: Treat the underlying IBD to resolve oral ulceration 2

Critical Pitfalls to Avoid

• Never rely solely on topical treatments for persistent ulcers without establishing definitive diagnosis—this delays identification of malignancy, lymphoma, or life-threatening systemic disease 2
• Do not assume small or benign-appearing lesions are non-malignant—squamous cell carcinoma can present as small white ulcerative lesions 3
• Never delay biopsy beyond 2 weeks for any persistent ulcer—this represents excessive delay in diagnosing potentially life-threatening conditions 2, 3
• Do not prematurely taper corticosteroids before disease control is established 2
• Avoid inadequate biopsy technique (too small or superficial) that misses diagnostic features 2
• Do not overlook systemic disease associations—fever with oral ulcers is a red flag for systemic involvement requiring urgent evaluation 2, 3

Specialist Referral Criteria

• Refer to oral medicine specialist or dermatologist for any ulcer lasting >2 weeks, not responding to 1-2 weeks of treatment, or accompanied by fever and systemic symptoms 2, 4
• Refer to rheumatology for suspected Behçet's disease 4
• Refer to gastroenterology when inflammatory bowel disease is suspected 4
• Oral medicine specialists can perform specialized diagnostic procedures including biopsies and coordinate multidisciplinary care 2