What is the recommended treatment for a patient presenting with an aphthous ulcer?

Treatment of Aphthous Ulcers

Start with topical corticosteroids as first-line therapy for aphthous ulcers, combined with topical anesthetics for pain control, and escalate to systemic therapies only for refractory or severe recurrent cases. 1, 2

First-Line Topical Therapy

Topical Corticosteroids (Primary Treatment)

For localized ulcers:

• Apply clobetasol propionate 0.05% gel or ointment directly to dried ulcer 2-4 times daily 1, 2
• Alternatively, use triamcinolone acetonide 0.1% paste applied 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 a rinse-and-spit preparation four times daily 1, 2, 3
• Alternatively, dexamethasone mouth rinse (0.1 mg/mL) can be used 1

Pain Management (Essential Adjunct)

• Apply viscous lidocaine 2% topically before meals, up to 3-4 times daily 1, 2, 3
• Use benzydamine hydrochloride rinse or spray every 3 hours, particularly before eating 1, 2, 3
• Consider topical NSAIDs such as amlexanox 5% oral paste for severe pain 1

Mucoprotective and Antiseptic Measures

• Apply Gelclair mucoprotectant gel three times daily to form a protective coating over ulcerated surfaces 1, 3
• Use antiseptic oral rinses twice daily: either 0.2% chlorhexidine digluconate or 1.5% hydrogen peroxide mouthwash 1, 2, 3
• Apply white soft paraffin ointment to lips every 2 hours if affected 1, 3
• Clean mouth daily with warm saline mouthwashes 1, 3

Second-Line Therapy for Refractory Cases

When topical therapy fails after 1-2 weeks:

Intralesional Steroids

• Administer intralesional triamcinolone injections weekly (total dose 28 mg) for persistent localized ulcers 1, 2, 3

Systemic Corticosteroids

• Prescribe prednisone or prednisolone 30-60 mg (or 1 mg/kg) for 1 week, then taper over the second week for highly symptomatic cases 1, 2, 3
• Critical pitfall to avoid: Do not taper corticosteroids prematurely before disease control is established 1

Alternative Topical Agent

• Try tacrolimus 0.1% ointment applied twice daily for 4 weeks as an alternative to triamcinolone 1, 3

Third-Line Therapy for Recurrent Aphthous Stomatitis

For patients with ≥4 episodes per year:

• Start colchicine as first-line systemic therapy, especially effective when erythema nodosum or genital ulcers are present 1, 2, 4, 5
• Consider azathioprine, interferon-alpha, or TNF-alpha inhibitors for resistant cases 1, 2
• Apremilast may be considered in selected refractory cases 1
• Thalidomide is the most effective treatment but use is limited by frequent adverse effects 4

Special Diagnostic Considerations

When to refer or biopsy:

• Refer patients to a specialist for oral ulcers lasting more than 2 weeks or not responding to 1-2 weeks of treatment 1, 2
• Biopsy is indicated for ulcers lasting over 2 weeks or not responding to treatment to rule out malignancy 1, 2
• Perform blood tests (full blood count, coagulation, fasting blood glucose, HIV antibody, syphilis serology) before biopsy to exclude contraindications and provide diagnostic clues 1

Supportive Measures and Lifestyle Modifications

• Avoid hard, acidic, salty foods and toothpastes containing sodium lauryl sulfate 5
• Avoid alcohol and carbonated drinks 5
• For dry mouth, recommend sugarless chewing gum, candy, or salivary substitutes 1
• Consider protein or amino acid supplementation to promote healing 2

Treatment for Secondary Candidal Infection

If candidal infection is suspected:

• Prescribe Nystatin oral suspension 100,000 units four times daily for 1 week 3
• Alternatively, use Miconazole oral gel 5-10 mL held in mouth after food four times daily for 1 week 3

Common Pitfalls to Avoid

• Do not use antiseptic agents or local anesthetics alone without attempting topical corticosteroids for definitive treatment 5
• Avoid premature tapering of systemic corticosteroids before achieving disease control 1
• Do not overlook underlying systemic conditions (celiac disease, inflammatory bowel disease, nutritional deficiencies, HIV, Behçet's disease) in patients with recurrent aphthous stomatitis 4, 5
• Every solitary chronic oral ulcer should be biopsied to rule out squamous cell carcinoma 4