What is the treatment for recurrent aphthous ulcers?

Treatment of Recurrent Aphthous Ulcers

Start with high-potency topical corticosteroids (clobetasol 0.05% gel or betamethasone 0.5mg/10ml rinse) applied 2-4 times daily as first-line therapy, combined with topical anesthetics for pain control before meals. 1

First-Line Topical Management

Topical Corticosteroids (primary treatment):

• For localized ulcers: Apply clobetasol gel or ointment 0.05% directly 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 2-4 times daily 1
• Alternative: Triamcinolone acetonide 0.1% paste applied directly to dried ulcer 2-4 times daily 1

Pain Control (use concurrently):

• Apply viscous lidocaine 2% before meals 1
• Use benzydamine hydrochloride rinse or spray every 3 hours, particularly before eating 1
• Consider amlexanox 5% oral paste for severe pain 1, 2

Barrier Protection:

• Apply mucoprotectant mouthwashes (e.g., Gelclair) three times daily 1
• Use white soft paraffin ointment to lips every 2 hours 1

Oral Hygiene Protocol

• Clean mouth daily with warm saline mouthwashes 1
• Use antiseptic oral rinses twice daily (1.5% hydrogen peroxide or 0.2% chlorhexidine digluconate) 1
• For dry mouth, recommend sugarless chewing gum, candy, or salivary substitutes 1

Second-Line Management for Refractory Cases

When topical therapy fails after 1-2 weeks 1:

• Intralesional steroids: Inject triamcinolone weekly (total dose 28 mg) for persistent localized ulcers 1
• 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

Third-Line Systemic Therapy for Recurrent Disease

For patients with ≥4 episodes per year 1:

• Colchicine is the preferred first-line systemic agent, especially effective when erythema nodosum or genital ulcers are present 1, 3
• For resistant cases, consider in order:
  • Azathioprine 1
  • Interferon-alpha 1
  • TNF-alpha inhibitors (infliximab or adalimumab) 1
  • Apremilast 1

Critical Pitfalls to Avoid

• Do not taper corticosteroids prematurely before disease control is established 1
• Do not continue same treatment if ulcers persist beyond 2 weeks without response 1
• Avoid sodium lauryl sulfate-containing toothpastes, hard/acidic/salty foods, alcohol, and carbonated drinks 4

When to Refer or Investigate Further

• Refer to specialist for ulcers lasting more than 2 weeks or not responding to 1-2 weeks of treatment 1
• Consider biopsy for ulcers lasting over 2 weeks or not responding to treatment to exclude malignancy 1
• Perform blood tests (full blood count, coagulation, fasting glucose, HIV antibody, syphilis serology) before biopsy to exclude contraindications and identify underlying causes 1

Evidence Quality Note

The strongest evidence supports topical corticosteroids as cornerstone therapy 1. While multiple topical agents have been studied, triamcinolone acetonide 0.1% and amlexanox 5% demonstrated statistically significant efficacy in reducing ulcer size, number, pain, erythema and exudate levels compared to placebo 2. Systemic therapies are supported by lower quality evidence but are reasonable for severe refractory cases 1, 4.