Aphthous Ulcer Treatment
Start with topical corticosteroids as first-line therapy for aphthous ulcers, applying clobetasol 0.05% ointment or gel directly to dried lesions twice daily for localized ulcers, or using betamethasone sodium phosphate 0.5 mg in 10 mL water as a rinse-and-spit solution four times daily for multiple or widespread ulcers. 1, 2
First-Line Topical Therapy
Topical Corticosteroids (Primary Treatment)
- For localized, accessible lesions: Apply clobetasol 0.05% ointment or gel directly to the dried ulcer twice daily 1, 2, 3
- For multiple or widespread ulcers: Use dexamethasone mouth rinse (0.1 mg/mL) or betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water as rinse-and-spit four times daily 1, 2, 3
- Alternative for localized lesions: Triamcinolone acetonide 0.1% paste applied directly to dried ulcer 2-4 times daily 2, 4
Pain Management (Essential Adjunct)
- Topical anesthetics: Viscous lidocaine 2% applied before meals, 3-4 times daily 1, 2, 3
- Benzydamine hydrochloride: Rinse or spray every 3 hours, particularly before eating 2, 3
- Topical NSAIDs: Amlexanox 5% oral paste for severe pain 2
Mucoprotectants and Antiseptics
- Barrier preparations: Gelclair or Gengigel applied three times daily for mucosal protection 1, 2
- Antiseptic rinses: 0.2% chlorhexidine digluconate mouthwash twice daily to prevent infection and promote healing 1, 2, 3
- Oral hygiene: Warm saline mouthwashes daily 2, 3
Second-Line Treatment for Refractory Cases
When to Escalate
Progress to second-line therapy when ulcers do not respond to 1-2 weeks of topical treatment 1, 2, 3
Intralesional Steroids
- Triamcinolone injections: Weekly administration, total dose 28 mg for persistent ulcers that don't respond to topical therapy 1, 2, 3
Systemic Corticosteroids
- Prednisone/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, 3
- Critical pitfall: Do not taper corticosteroids prematurely before disease control is established 2, 3
Systemic Immunomodulators (For Recurrent Aphthous Stomatitis)
- Colchicine: First-line systemic therapy for patients with recurrent ulcers (≥4 episodes per year), especially effective when erythema nodosum or genital ulcers are present 2, 5, 6
- Refractory cases: Consider azathioprine, interferon-alpha, TNF-alpha inhibitors, or apremilast 1, 2
- Thalidomide: Most effective treatment but use limited by frequent adverse effects 5
Supportive Measures
Dietary Modifications
- Avoid hard, acidic, salty foods 6
- Avoid alcohol and carbonated drinks 6
- Recommend soft, moist foods served at room temperature or cold 3
- Avoid toothpastes containing sodium lauryl sulfate 6
Dry Mouth Management
Critical Red Flags and Referral Criteria
When to Refer to Specialist
- Ulcers persisting beyond 2 weeks despite treatment 1, 2, 3
- No response to 1-2 weeks of treatment 1, 2, 3
- Biopsy indication: Any chronic solitary ulcer requires biopsy to rule out squamous cell carcinoma 2, 5
Diagnostic Workup Before Escalation
- Consider blood tests including full blood count, coagulation studies, fasting glucose, HIV antibody, and syphilis serology before biopsy 2
- Evaluate for underlying systemic conditions: celiac disease, inflammatory bowel disease, nutritional deficiencies (iron, folates), immune disorders 5, 6
Treatment Algorithm Summary
Step 1: Begin with topical corticosteroids (clobetasol 0.05% for localized or betamethasone rinse for widespread) plus topical anesthetics for pain 1, 2, 3
Step 2: Add mucoprotectants and antiseptic rinses for supportive care 1, 2, 3
Step 3: If no improvement after 1-2 weeks, escalate to intralesional triamcinolone injections 1, 2, 3
Step 4: For highly symptomatic cases or recurrent disease (≥4 episodes/year), initiate systemic corticosteroids or colchicine 1, 2, 5
Step 5: Refer to specialist if ulcers persist beyond 2 weeks or consider immunosuppressive agents for refractory cases 1, 2, 3