What is the first line of treatment for a patient with recurrent aphthous ulcers?

First-Line Treatment for Recurrent Aphthous Ulcers

Topical corticosteroids are the first-line treatment for recurrent aphthous ulcers, with the specific formulation chosen based on ulcer location and extent. 1

Initial Topical Steroid Approach

For localized, accessible ulcers:

• Apply clobetasol gel or ointment 0.05% directly to the dried ulcer 2-4 times daily 1
• Alternatively, use triamcinolone acetonide 0.1% paste applied directly to dried ulcer 2-4 times daily 1

For multiple or widespread ulcers:

• Use dexamethasone mouth rinse (0.1 mg/ml) or betamethasone sodium phosphate 0.5 mg in 10 ml water as a rinse-and-spit preparation four times daily 1

Essential Adjunctive Pain Control

Pain management should be initiated concurrently with topical steroids:

• Apply viscous lidocaine 2% before meals to enable adequate nutritional intake 1
• Use benzydamine hydrochloride rinse or spray every 3 hours, particularly before eating 1
• Consider topical NSAIDs such as amlexanox 5% oral paste for severe pain 1, 2

Supportive Barrier and Hygiene Measures

These measures enhance healing and prevent secondary infection:

• Apply mucoprotectant mouthwashes (e.g., Gelclair) three times daily to create a protective barrier 1
• Use antiseptic oral rinses twice daily (1.5% hydrogen peroxide or 0.2% chlorhexidine digluconate) 1
• Clean the mouth daily with warm saline mouthwashes 1
• Apply white soft paraffin ointment to lips every 2 hours if lip involvement present 1

When to Escalate Beyond First-Line Therapy

If ulcers do not respond to 1-2 weeks of topical treatment, escalation is warranted 1:

For persistent localized ulcers:

• Intralesional triamcinolone injections weekly (total dose 28 mg) 1

For highly symptomatic or recurrent ulcers (≥4 episodes per year):

• Systemic corticosteroids: prednisone/prednisolone 30-60 mg or 1 mg/kg for 1 week with tapering over the second week 1
• Colchicine as first-line systemic therapy, especially effective if erythema nodosum or genital ulcers are also present 1, 3

For refractory cases unresponsive to the above:

• Consider azathioprine, interferon-alpha, TNF-alpha inhibitors, or apremilast 1
• Thalidomide is the most effective treatment for severe RAS but use is limited by frequent adverse effects 3, 4

Critical Pitfalls to Avoid

• Do not taper corticosteroids prematurely before disease control is established, as this leads to treatment failure 1
• Refer to a specialist for oral ulcers lasting more than 2 weeks or not responding to 1-2 weeks of treatment to exclude malignancy or other serious conditions 1
• Perform blood tests (full blood count, coagulation, fasting blood glucose, HIV antibody, syphilis serology) before biopsy if ulcers persist, to exclude contraindications and provide diagnostic clues 1
• Consider underlying systemic conditions (celiac disease, inflammatory bowel disease, nutritional deficiencies, Behçet's disease) in patients with frequent recurrences 3, 5