What is the difference in treatment between aphthous stomatitis and oral herpes?

Aphthous Stomatitis vs Oral Herpes: Treatment Differences

Aphthous stomatitis requires topical corticosteroids and supportive care, while oral herpes requires antiviral therapy—antivirals are completely ineffective for aphthous ulcers and should never be used for this condition. 1

Critical Distinction: Why This Matters

The fundamental difference is that aphthous stomatitis is NOT caused by herpes simplex virus and will not respond to antiviral medications 1, 2. This is a common clinical error that leads to inappropriate treatment and patient frustration. Research definitively shows oral acyclovir has no effect on preventing or treating aphthous stomatitis recurrences 1.

Clinical Differentiation Before Treatment

Oral Herpes (HSV) Characteristics:

• Prodrome: Itching, burning, or tingling sensation before lesion appearance 3
• Lesion progression: Erythema → papule → vesicle → pustule → ulcer → crusting 3
• Location: Typically on keratinized mucosa (lips, hard palate, gingiva) or perioral skin 4, 5
• Appearance: Clustered vesicles that rupture into painful ulcers with erythematous halos 5
• Peak viral shedding: First 24 hours after lesion onset when vesicles are present 3

Aphthous Stomatitis Characteristics:

• No vesicular stage: Lesions begin as erythematous areas that develop into ulcers directly 4, 2
• Location: Non-keratinized mucosa (buccal mucosa, tongue, soft palate, floor of mouth) 4, 2
• Appearance: Round or oval ulcers with gray-white pseudomembrane and erythematous border 6
• No crusting: Lesions heal without scab formation 2

Treatment Algorithm for Oral Herpes

Timing is Critical:

Treatment must be initiated within the first 24 hours of symptom onset for optimal benefit 3. The natural healing process begins within 24 hours, so delayed treatment offers minimal therapeutic advantage 3.

First-Line Antiviral Therapy:

• Valacyclovir 2 grams twice daily for 1 day (FDA-approved regimen for herpes labialis) 7
• Alternative: Valacyclovir 2 grams twice daily on Day 1, followed by 1 gram twice daily on Day 2 7
• Oral acyclovir for primary herpetic gingivostomatitis reduces healing time 3
• Topical antivirals (applied 5-6 times daily for up to 5 days) provide small clinical benefit but are less convenient than oral therapy 3

Adjunctive Therapy:

• Topical acyclovir/hydrocortisone combination can limit inflammatory cascade when applied 5-6 times daily 3
• Topical corticosteroids may reduce inflammation but should only be used with concurrent antiviral coverage 3

Prophylaxis for Frequent Recurrences:

• Chronic suppressive therapy with systemic antivirals for patients with severe, frequent, or complicated disease 3
• Sunscreen or zinc oxide application to prevent UV-triggered reactivation 3

Treatment Algorithm for Aphthous Stomatitis

Mild RAS:

• Sodium bicarbonate rinses 4-6 times daily as foundational therapy 8
• Topical anesthetics: Viscous lidocaine 2% for pain control 8
• Benzydamine hydrochloride rinses every 3 hours, especially before eating 8
• Barrier preparations (Gengigel, Gelclair) for symptom relief 8

Moderate RAS:

• Increase sodium bicarbonate rinses to hourly if needed 8
• High-potency topical corticosteroids as first-line therapy 8:
  • Betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water, rinse-and-spit 1-4 times daily 8
  • Fluticasone propionate nasules diluted in 10 mL water twice daily 8
  • Clobetasol 0.05% ointment mixed in 50% Orabase applied twice weekly to localized lesions 8

Severe or Recalcitrant RAS:

• Intralesional triamcinolone injections (total dose 28 mg) with topical clobetasol gel/ointment 8
• Systemic corticosteroids: High-dose pulse 30-60 mg or 1 mg/kg oral prednisone/prednisolone for 1 week, then taper over second week 8
• Tacrolimus 0.1% ointment applied twice daily for 4 weeks for resistant cases 8

Essential Supportive Care for Both Conditions:

• Non-alcoholic mouthwashes containing sodium bicarbonate 8, 9
• Soft, moist, non-irritating foods; avoid acidic, spicy, salty foods 8, 9
• Adequate hydration with plenty of water 8, 9
• Ice chips or ice pops for temporary pain relief 8, 9
• Lip balm for dry lips 8, 9

Critical Pitfalls to Avoid

Never prescribe antivirals for aphthous stomatitis—they are completely ineffective and waste resources while delaying appropriate corticosteroid therapy 1, 2. This is one of the most common errors in managing oral ulcers 2.

Never use corticosteroids for suspected herpes without antiviral coverage—this can worsen viral replication and extend disease duration 9. If diagnostic uncertainty exists, laboratory confirmation should be obtained before initiating corticosteroid therapy 3.

Treat concurrent candidal infections with nystatin or miconazole when using topical corticosteroids for aphthous stomatitis, as steroids increase fungal infection risk 8.

Laboratory confirmation may be necessary in immunocompromised patients or when clinical presentation is atypical, as both conditions can present differently in these populations 3.