What is the best treatment approach for a patient with aphthous ulcers?

Treatment of Aphthous Ulcers

Start with topical corticosteroids as first-line therapy, specifically betamethasone sodium phosphate 0.5 mg in 10 mL water as a rinse-and-spit preparation four times daily for widespread ulcers, or clobetasol 0.05% gel/ointment applied directly to dried localized lesions 2-4 times daily. 1, 2, 3

First-Line Topical Therapy

Corticosteroid Selection Based on Ulcer Distribution

• For localized, accessible ulcers: Apply clobetasol propionate 0.05% ointment (can be mixed 1:1 with Orabase) directly to dried ulcer surfaces 2-4 times daily 1, 2, 3
• For multiple or widespread ulcers: Use betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water as a 3-minute rinse-and-spit solution 2-4 times daily 1, 2, 3
• Alternative for widespread disease: Dexamethasone mouth rinse 0.1 mg/mL 1, 3
• For persistent localized lesions: Triamcinolone acetonide 0.1% paste applied to dried ulcer 2-4 times daily 1

Pain Management (Use Concurrently)

• Before meals: Apply viscous lidocaine 2% topically up to 3-4 times daily 1, 2, 3
• Every 3 hours, especially before eating: Benzydamine hydrochloride oral rinse or spray 1, 2, 3
• For severe pain: Topical NSAIDs such as amlexanox 5% oral paste 1

Mucosal Protection and Hygiene

• Three times daily: Apply Gelclair mucoprotectant gel to form protective coating over ulcerated surfaces 1, 2, 3
• If lips affected: White soft paraffin ointment every 2 hours 1, 2
• Daily oral hygiene: Warm saline mouthwashes 1, 2
• Twice daily: Antiseptic rinses with either 0.2% chlorhexidine digluconate or 1.5% hydrogen peroxide 1, 2, 3

Second-Line Therapy for Refractory Cases

When to Escalate Treatment

Progress to second-line therapy if ulcers fail to respond after 1-2 weeks of appropriate topical treatment 1, 3

Intralesional Steroids

• For persistent localized ulcers: Intralesional triamcinolone injections weekly (total dose 28 mg) in conjunction with topical clobetasol 1, 2, 3

Systemic Corticosteroids

• For highly symptomatic or recurrent ulcers: Prednisone/prednisolone 30-60 mg daily (or 1 mg/kg) for 1 week, then taper over the second week 1, 2, 3
• Pediatric dosing: 1-1.5 mg/kg/day up to maximum 60 mg for severe cases 1

Critical pitfall: Do not taper corticosteroids prematurely before disease control is established 1

Alternative Systemic Agents

• For recurrent aphthous stomatitis (≥4 episodes/year): Consider colchicine as first-line systemic therapy, particularly effective if patient also has erythema nodosum or genital ulcers 1, 2, 3, 4
• For resistant cases unresponsive to colchicine: Consider azathioprine, interferon-alpha, or TNF-alpha inhibitors 1, 3
• Alternative option: Tacrolimus 0.1% ointment applied twice daily for 4 weeks 1, 2

Special Considerations

When to Refer

• Refer to specialist: Any oral ulcer lasting more than 2 weeks or not responding to 1-2 weeks of treatment 1, 3
• Biopsy indication: Ulcers persisting beyond 2 weeks to rule out malignancy, particularly solitary chronic ulcers which may represent squamous cell carcinoma 1, 4

Behçet's Disease

• Initial approach: Start with topical corticosteroids 1
• Add colchicine: For recurrent mucocutaneous involvement 1
• For refractory cases: Progress to azathioprine, interferon-alpha, or TNF-alpha antagonists 1
• Alternative with RCT evidence: Sucralfate suspension for oral and genital ulcers 1

Lifestyle Modifications

• Avoid: Hard, acidic, salty foods; toothpastes containing sodium lauryl sulfate; alcohol; carbonated drinks 5
• For dry mouth: Recommend sugarless chewing gum, candy, or salivary substitutes 1

Diagnostic Workup Before Treatment

• Pre-biopsy blood tests: Full blood count, coagulation studies, fasting glucose, HIV antibody, syphilis serology to exclude contraindications and provide diagnostic clues 1
• Consider underlying causes: Screen for celiac disease, inflammatory bowel disease, nutritional deficiencies (iron, folates), immune disorders (HIV, neutropenia) in recurrent cases 4, 5

Treatment Algorithm Summary

The evidence strongly supports a stepwise approach: begin with topical corticosteroids matched to ulcer distribution, add pain control measures, maintain oral hygiene with antiseptic rinses, and escalate to intralesional or systemic therapy only after documented failure of topical treatment for 1-2 weeks. 1, 2, 3 The quality of evidence for systemic interventions remains limited, with most trials showing methodological weaknesses, but clinical experience supports their use in refractory cases. 6