What are the treatment options for a patient with aphthous ulcers?

Treatment of Aphthous Ulcers

Start with topical corticosteroids as first-line therapy for aphthous ulcers, applying them directly to accessible lesions 2-4 times daily, and add topical anesthetics for pain control before meals. 1, 2

First-Line Topical Therapy

Topical Corticosteroids (Primary Treatment)

For localized ulcers:

• Apply clobetasol 0.05% ointment mixed in equal amounts with Orabase directly to dried ulcers twice daily 1, 2, 3
• Alternatively, use triamcinolone acetonide 0.1% paste applied directly to dried ulcer 2-4 times daily 2, 4

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, 2, 3
• Alternatively, dexamethasone mouth rinse (0.1 mg/mL) can be used for difficult-to-reach areas 1, 2

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 amlexanox 5% oral paste for severe pain 2

Mucoprotectants and Antiseptics

• Apply Gelclair mucoprotectant gel three times daily to form a protective coating over ulcerated surfaces 1, 2, 3
• Use 0.2% chlorhexidine digluconate antiseptic oral rinse twice daily to prevent infection and promote healing 1, 2, 3
• Apply white soft paraffin ointment to lips every 2 hours if affected 2, 3

Second-Line Therapy for Refractory Cases

When topical therapy fails after 1-2 weeks, escalate treatment systematically: 1, 2

Intralesional Steroids

• Administer intralesional triamcinolone injections weekly (total dose 28 mg) for persistent 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 or recurrent ulcers 1, 2
• Critical pitfall: Do not taper corticosteroids prematurely before disease control is established 2

Alternative Topical Agent

• Try tacrolimus 0.1% ointment applied twice daily for 4 weeks as an alternative to triamcinolone 2, 3

Third-Line Therapy for Recurrent Aphthous Stomatitis

For patients with ≥4 episodes per year (recurrent aphthous stomatitis): 2, 5, 6

• Start colchicine as first-line systemic therapy, especially effective for patients with erythema nodosum or genital ulcers 2, 5, 6
• Consider azathioprine, interferon-alpha, or TNF-alpha inhibitors for resistant cases 1, 2
• Apremilast may be considered in selected refractory cases 2
• Thalidomide is the most effective treatment but use is limited by frequent adverse effects 5

Supportive Measures

Oral Hygiene

• Clean the mouth daily with warm saline mouthwashes to reduce bacterial colonization 2, 3
• Use 1.5% hydrogen peroxide mouthwash twice daily as an alternative antiseptic 2, 3

Dietary Modifications

• Avoid hard, acidic, salty foods, alcohol, and carbonated drinks 6
• Avoid toothpastes containing sodium lauryl sulfate 6

Nutritional Support

• Consider protein or amino acid supplementation to promote healing 1

When to Refer and Investigate

Red flags requiring specialist referral: 2

• Ulcers lasting more than 2 weeks despite treatment
• Ulcers not responding to 1-2 weeks of appropriate therapy
• Biopsy is indicated to rule out malignancy in these cases 1, 2

Pre-biopsy workup should include: 2

• Full blood count
• Coagulation studies
• Fasting blood glucose
• HIV antibody testing
• Syphilis serology

Common Pitfalls to Avoid

• Do not use conventional therapeutic shoes or chemical agents to treat aphthous ulcers (this applies to foot ulcers, not oral aphthous ulcers) 1
• Do not taper steroids prematurely before achieving disease control 2
• Do not delay referral for chronic ulcers that may represent malignancy 2
• Ensure proper diagnosis before initiating treatment, as many conditions can mimic aphthous ulcers 3, 5