What is the best management approach for a previously healthy adult with painful oral ulcers and a very painful throat, without genital ulcers or fever?

Management of Painful Oral Ulcers with Severe Throat Pain (Without Genital Ulcers or Fever)

Begin immediate topical therapy with high-potency corticosteroids and aggressive pain control, as this presentation most likely represents severe recurrent aphthous stomatitis or a related inflammatory condition requiring prompt symptomatic management. 1

Immediate First-Line Treatment

Topical Corticosteroids

• Apply betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water as a rinse-and-spit preparation four times daily for widespread oral and throat involvement 1, 2
• For any localized accessible ulcers, apply clobetasol propionate 0.05% gel or ointment directly to dried lesions 1
• Alternatively, use dexamethasone mouth rinse (0.1 mg/mL) for difficult-to-reach posterior throat areas 1

Aggressive Pain Management

• Use benzydamine hydrochloride rinse or spray every 3 hours, particularly before eating, as this provides both analgesic and anti-inflammatory effects 1, 2
• Apply viscous lidocaine 2% topically before meals to enable oral intake 1, 2
• Consider topical NSAIDs such as amlexanox 5% oral paste for severe pain 1

Mucosal Protection

• Apply Gelclair mucoprotectant gel three times daily to form a protective coating over ulcerated surfaces 1, 2
• Apply white soft paraffin ointment to lips every 2 hours if lips are affected 1, 2

Oral Hygiene

• Clean the mouth daily with warm saline mouthwashes to reduce bacterial colonization 1, 2
• Use antiseptic oral rinses twice daily (1.5% hydrogen peroxide or 0.2% chlorhexidine digluconate) 1, 2

Critical Diagnostic Considerations

If ulcers persist beyond 2 weeks or fail to respond to 1-2 weeks of treatment, urgent specialist referral and biopsy are indicated to rule out malignancy, systemic disease, or atypical infections. 3, 1

Pre-Biopsy Workup (if ulcers persist >2 weeks)

Before proceeding to biopsy, obtain:

• Full blood count (to detect anemia, leukemia, or blood disorders) 3
• Coagulation studies and fasting blood glucose 3
• HIV antibody and syphilis serology 3
• These tests exclude biopsy contraindications and provide diagnostic clues 3, 1

Red Flags Requiring Immediate Investigation

• Ulcers persisting >2 weeks despite treatment mandate biopsy 3, 1
• History of recent medication exposure (consider drug-induced ulceration or Stevens-Johnson syndrome) 4
• Immunosuppression or diabetes (raises concern for invasive fungal infection) 3
• History of tuberculosis, inflammatory bowel disease, or autoimmune conditions 3

Second-Line Management for Refractory Cases

If topical therapy fails after 1-2 weeks:

Systemic Corticosteroids

• Prescribe prednisone/prednisolone 30-60 mg (or 1 mg/kg) daily for 1 week, then taper over the second week for highly symptomatic or recurrent ulcers 1, 2
• Do not taper prematurely before disease control is established 1

Alternative Systemic Therapies

• Consider colchicine as first-line systemic therapy for recurrent aphthous stomatitis (≥4 episodes per year), particularly if there is any history of erythema nodosum 1, 5
• For truly refractory cases, consider azathioprine, interferon-alpha, or TNF-alpha inhibitors in consultation with specialists 1

Intralesional Therapy

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

Important Differential Diagnoses to Consider

Infectious Causes (Despite Absence of Fever)

• Primary syphilis can present with oral/pharyngeal ulcers without fever - the recent case of a syphilitic uvula ulcer demonstrates this 6
• Herpes simplex virus (though typically presents with vesicles before ulceration) 7, 8
• Consider testing for syphilis serology and HSV PCR if risk factors present 3, 7

Drug-Induced or Immune-Mediated

• Stevens-Johnson syndrome/toxic epidermal necrolysis must be ruled out if there is any history of new medication in the past 1-3 weeks, even without fever initially 4
• Behçet's syndrome (though typically includes genital ulcers, oral-only presentations occur) 1, 5
• Inflammatory bowel disease-associated oral ulcers 3, 5

Malignancy

• Any solitary chronic oral ulcer requires biopsy to exclude squamous cell carcinoma 5

Common Pitfalls to Avoid

• Do not delay topical therapy while awaiting diagnostic workup - begin symptomatic treatment immediately 4
• Do not assume absence of fever rules out serious pathology - primary syphilis, early malignancy, and drug reactions may not present with fever 6
• Do not overlook medication history - fixed drug eruptions and drug-induced ulceration are important considerations 7, 8
• Do not restart any potentially causative medications without specialist consultation 4
• Ensure adequate nutritional support if pain prevents oral intake 3

Follow-Up Strategy

• Reassess response to treatment at 1 week 1
• If no improvement after 1-2 weeks of appropriate topical therapy, proceed to specialist referral and diagnostic workup 3, 1
• Monitor for development of genital ulcers or systemic symptoms that would suggest Behçet's syndrome or other systemic disease 1, 5
• Daily examination of oral surfaces to assess progression and detect secondary infections 4