Treatment of Aphthous Ulcers in Pediatric Patients
Begin with topical corticosteroids and supportive care as first-line therapy for aphthous ulcers in children, reserving systemic treatments only for severe refractory cases. 1, 2, 3
First-Line Management: Pain Control and Supportive Care
Systemic Pain Relief
- Administer oral acetaminophen at age-appropriate dosing for systemic pain management 1, 2
- Apply benzydamine hydrochloride rinse or spray every 3 hours, particularly before meals, to facilitate eating 1, 3
Local Anesthetic Options
- Use topical 2.5% lidocaine ointment cautiously, applying sparingly to avoid accidental ingestion and systemic absorption 2, 3
- Consider viscous lidocaine 2% mouthwash before meals for older children who can safely rinse and spit 3
Oral Hygiene and Barrier Protection
- Clean the mouth daily with warm saline mouthwashes to reduce bacterial colonization 1, 2
- For infants, parents can use a clean finger wrapped in gauze soaked in warm saline to gently clean affected areas 2
- Apply white soft paraffin ointment to lips every 2 hours if lesions involve the lips 1, 2
- Use mucoprotectant preparations (such as Gelclair or Gengigel) three times daily for barrier protection 1, 3
Second-Line Management: Topical Corticosteroids
Topical steroids should be reserved exclusively for non-infectious causes such as aphthous ulcers or inflammatory conditions—never use for viral or bacterial infections. 1
For Localized Lesions
- Apply triamcinolone acetonide 0.1% paste directly to dried ulcer 2-4 times daily 1, 3
- Alternatively, use clobetasol 0.05% ointment mixed in 50% Orabase applied twice weekly to dried mucosa for more severe localized ulcers 3
For Multiple or Widespread Ulcers
- Use betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water as a rinse-and-spit solution 2-4 times daily 1, 3
- Alternatively, consider dexamethasone mouth rinse (0.1 mg/mL) for difficult-to-reach ulcers 3, 4
For Infants with Accessible Lesions
- Apply clobetasol propionate 0.05% cream or ointment topically to affected areas in very small amounts 2
Third-Line Management: Refractory Cases
Intralesional Therapy
- Consider intralesional triamcinolone injections weekly (total dose 28 mg) for persistent ulcers not responding to topical therapy 3
Systemic Corticosteroids
- Reserve for highly symptomatic or recurrent ulcers: prednisone/prednisolone at 1-1.5 mg/kg/day (maximum 40-60 mg) for 1 week with tapering over the second week 3, 4
- Avoid systemic corticosteroids for simple aphthous ulcers unless absolutely necessary, as premature use can mask serious underlying conditions 1, 2
Alternative Systemic Agents
- For recurrent aphthous stomatitis (≥4 episodes per year), consider colchicine as first-line systemic therapy 3, 5
- For severe recalcitrant cases, azathioprine, interferon-alpha, or TNF-alpha inhibitors may be necessary 3, 6
When to Refer to a Specialist
- Refer if the ulcer persists beyond 2 weeks 1, 3
- Refer if there is no response to 1-2 weeks of treatment 1, 3
- Obtain detailed history focusing on recent viral illness, trauma, medication exposure, systemic symptoms, and family history of recurrent ulcers 1
- Recurrent ulcers warrant evaluation for underlying conditions including nutritional deficiencies (iron, folates), gastrointestinal disorders (celiac disease, inflammatory bowel disease), or immunologic abnormalities 1, 5
Critical Pitfalls to Avoid
- Never use topical corticosteroids for suspected viral or bacterial infections, as this can worsen the condition 1
- Do not taper corticosteroids prematurely before disease control is established 3
- Limit topical lidocaine application frequency and amount in young children due to risk of systemic absorption and potential toxicity 1, 2
- Avoid petroleum-based products that carry risk of accidental oral ingestion in young children 2