Inhaled Corticosteroids and Mouth Ulcer Pain
Inhaled corticosteroids like Forocort (formoterol/budesonide combination) and budesonide do not typically cause mouth ulcers, but they commonly cause oropharyngeal candidiasis (oral thrush) and throat irritation, which can present as mouth and throat pain that may be mistaken for ulcers.
Primary Oral Adverse Effects
The most well-documented oral side effects of inhaled corticosteroids are:
Oropharyngeal candidiasis (oral thrush) occurs with increased frequency in patients using inhaled corticosteroids, presenting as white patches in the mouth and throat that can cause pain and discomfort 1.
Throat irritation is a common adverse effect reported in clinical trials of inhaled corticosteroids, which can manifest as soreness and pain in the mouth and throat 1.
The FDA label for budesonide specifically warns that localized infections with Candida albicans occur in the mouth and pharynx, and these infections may require treatment with antifungal therapy 2.
Distinguishing Features
While true mouth ulcers are not a characteristic side effect:
Oral candidiasis appears as redness or white-colored patches in the mouth or throat, which can be painful and may be confused with ulcers 2.
The incidence of oral candidiasis is significantly increased with inhaled corticosteroid use (OR 2.65,95% CI 2.03-3.46) according to the American College of Chest Physicians 3.
Patients may experience a "sore mouth/throat" as a distinct symptom from candidiasis, which was reported as a common side effect in clinical studies 4.
Risk Mitigation Strategies
The most critical preventive measure is proper mouth rinsing after each use:
Patients should rinse their mouth with water and spit it out after each budesonide inhalation treatment to reduce the risk of fungal infections 2.
Using large-volume spacers with the inhaler can minimize oral deposition and reduce local side effects 1, 5.
Despite guideline recommendations, approximately 30.5% of patients report suboptimal mouth rinsing practices, which increases their risk of oropharyngeal adverse effects 4.
Receiving advice from a healthcare professional significantly increases the likelihood of correct mouth rinsing implementation (P < 0.001) 4.
Rare Allergic Reactions
In exceptional cases, true allergic reactions can occur:
Severe type IV contact allergy to budesonide has been documented, presenting with angioedema, swelling of the lips and oral cavity, and dysphagia developing 3-4 hours after use 6.
Hypersensitivity reactions including rash, contact dermatitis, urticaria, angioedema, and bronchospasm have been reported with budesonide use, though these are uncommon 2.
If such allergic reactions occur, budesonide should be discontinued immediately 2.
Clinical Management
If a patient reports mouth pain while using Forocort or budesonide:
Examine the oral cavity for white patches or redness consistent with candidiasis rather than true ulceration 2.
Verify the patient is rinsing their mouth properly after each use, as this simple intervention prevents most oral complications 2, 4.
If candidiasis is present, treat with appropriate local or systemic antifungal therapy while continuing the inhaled corticosteroid if asthma control requires it 2.
Consider switching to a different corticosteroid formulation if symptoms persist despite proper technique and treatment, as fluticasone is more likely to cause systemic effects compared to budesonide 7.
If true allergic symptoms develop (rapid swelling, severe pain, difficulty swallowing), discontinue the medication immediately and consider alternative corticosteroids from different chemical groups 6.