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

Aphthous Stomatitis vs Oral Herpes: Treatment Differences

The fundamental treatment difference is that oral herpes requires antiviral therapy (acyclovir, valacyclovir, or famciclovir), while aphthous stomatitis is managed with topical corticosteroids and supportive care—using antivirals for aphthous ulcers is ineffective and corticosteroids for herpes simplex virus can dangerously potentiate the infection. 1, 2

Critical Diagnostic Distinction

Before initiating treatment, you must differentiate between these conditions as they require opposite therapeutic approaches:

• Oral herpes (HSV) presents with vesicles that rupture into ulcers, often with prodromal tingling, and may have systemic symptoms 1
• Aphthous stomatitis (RAS) presents with painful ulcers without preceding vesicles, typically on non-keratinized mucosa 3, 4
• The distinction is essential because corticosteroids potentiate HSV infection and should be avoided in herpes, while antivirals are ineffective for aphthous ulcers 1, 2

Treatment Algorithm for Oral Herpes (HSV)

First-Line Antiviral Therapy

Initiate antiviral treatment immediately upon clinical suspicion or confirmed diagnosis:

• Topical options: Ganciclovir 0.15% gel 3-5 times daily OR trifluridine 1% solution 5-8 times daily 1
• Oral antivirals (preferred for systemic coverage):
  • Acyclovir 200-400 mg five times daily 1
  • Valacyclovir 500 mg 2-3 times daily 1
  • Famciclovir 250 mg twice daily 1

Important Caveats for HSV Treatment

• Topical trifluridine causes epithelial toxicity if used beyond 2 weeks 1
• Topical ganciclovir is less toxic to the ocular surface 1
• Oral antivirals alone may not prevent progression of HSV blepharoconjunctivitis; adding topical antiviral is more effective 1
• Never use topical corticosteroids for HSV as they potentiate infection 1

Treatment Algorithm for Aphthous Stomatitis (RAS)

Foundational Care (All Severity Levels)

• Non-alcoholic sodium bicarbonate mouthwash 4-6 times daily 3, 5
• Good oral hygiene with gentle brushing 3, 5
• Soft, moist, non-irritating foods 3, 5

Mild RAS

• Continue sodium bicarbonate rinses 4-6 times daily 3
• Topical anesthetics: viscous lidocaine 2% for pain control 1, 3
• Benzydamine hydrochloride rinse every 3 hours, especially before eating 3
• Barrier preparations (Gengigel, Gelclair) for pain 3

Moderate RAS

• Increase sodium bicarbonate mouthwash frequency up to hourly 1, 3
• Topical high-potency corticosteroids (first-line):
  • Betamethasone sodium phosphate 0.5 mg in 10 mL water, rinse-and-spit 1-4 times daily 3
  • Fluticasone propionate nasules diluted in 10 mL water twice daily 3
  • Clobetasol 0.05% ointment mixed in 50% Orabase applied twice weekly for localized lesions 3
• Topical NSAIDs: amlexanox 5% oral paste for moderate pain 1, 5

Severe or Recalcitrant RAS

• Systemic corticosteroids: Prednisone 30-60 mg (or 1 mg/kg) daily for 1 week, then taper over second week 1, 3, 5
• Intralesional triamcinolone injections (28 mg total dose weekly) plus topical clobetasol 0.05% for non-resolving ulcers 1, 3
• Tacrolimus 0.1% ointment twice daily for 4 weeks in resistant cases 3

Key Pitfalls to Avoid

Misdiagnosis Consequences

• Using antivirals for aphthous stomatitis is ineffective—a study of 44 patients showed oral acyclovir had no effect on aphthous stomatitis recurrence rates 2
• Using corticosteroids for HSV infection worsens the disease and can lead to severe complications 1

Treatment Errors

• Alcoholic mouthwashes aggravate both conditions through mucosal irritation 5
• Topical trifluridine beyond 2 weeks causes significant epithelial toxicity 1
• Inadequate pain control in severe stomatitis leads to poor oral intake and potential treatment discontinuation 5

Concurrent Infections

• Always treat concurrent candidal infections with nystatin oral suspension or miconazole oral gel in aphthous stomatitis patients 3, 6
• Assess for secondary bacterial infection in angular involvement 6

Follow-Up Considerations

• HSV patients: Re-evaluate within 1 week with visual acuity measurement and slit-lamp biomicroscopy 1
• RAS patients: Monitor response to topical corticosteroids; if no improvement after 2 weeks, escalate to systemic therapy 3, 5
• Consider prophylactic low-dose oral antivirals for recurrent HSV keratitis 1