Treatment of Aphthous Ulcers
Begin with topical corticosteroids as first-line therapy, selecting betamethasone sodium phosphate rinse (0.5 mg in 10 mL water) for multiple ulcers or clobetasol 0.05% ointment for localized lesions, applied 2-4 times daily. 1, 2
First-Line Topical Therapy
Topical Corticosteroids (Primary Treatment)
- For localized, accessible ulcers: Apply clobetasol gel or ointment 0.05% directly to dried ulcer 2-4 times daily 1, 2
- For multiple or widespread ulcers: Use betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water as rinse-and-spit solution 2-4 times daily 1, 2
- Alternative for localized lesions: Triamcinolone acetonide 0.1% paste applied directly to dried ulcer 2-4 times daily 1
- For more severe localized ulcers: Clobetasol 0.05% ointment mixed in 50% Orabase applied twice weekly to dried mucosa 1
- Alternative rinse option: Dexamethasone mouth rinse 0.1 mg/mL 1, 2
Pain Control Measures
- Before meals: Apply viscous lidocaine 2% topical anesthetic mouthwash 1, 2
- Every 3 hours, particularly before eating: Use benzydamine hydrochloride rinse or spray 1, 2
- For severe pain: Consider topical NSAIDs such as amlexanox 5% oral paste 1
Barrier and Protective Agents
- Three times daily: Apply mucoprotectant mouthwashes (e.g., Gelclair or Gengigel) 1, 2
- Every 2 hours: Apply white soft paraffin ointment to lips 1
- Topical sucralfate: Can be used as first-line therapy alongside other topical treatments 3
Antiseptic Oral Hygiene
- Daily: Clean mouth with warm saline mouthwashes 1
- Twice daily: Use antiseptic oral rinses such as 0.2% chlorhexidine digluconate or 1.5% hydrogen peroxide 1, 2
Second-Line Management for Refractory Cases
When Topical Therapy Fails After 1-2 Weeks
- Intralesional steroids: Administer triamcinolone injections weekly (total dose 28 mg) for persistent ulcers 1, 2
- Systemic corticosteroids: Prescribe prednisone or prednisolone 30-60 mg (or 1 mg/kg) for 1 week with tapering over the second week for highly symptomatic cases 1, 2
- Pediatric dosing: 1-1.5 mg/kg/day up to maximum 60 mg 1
For Recurrent Aphthous Stomatitis (≥4 Episodes Per Year)
- First-line systemic therapy: Colchicine, especially effective for patients with concurrent erythema nodosum or genital ulcers 1, 2
- For resistant cases: Consider azathioprine, interferon-alpha, TNF-alpha inhibitors, or apremilast 1, 2
- Alternative option: Tacrolimus 0.1% ointment applied twice daily for 4 weeks 1
Critical Pitfalls to Avoid
- Do not taper corticosteroids prematurely before disease control is established 1
- Refer to specialist if ulcers persist beyond 2 weeks or do not respond to 1-2 weeks of treatment 1, 2
- Perform biopsy for ulcers lasting over 2 weeks to rule out malignancy 1, 2
- Avoid sodium lauryl sulfate-containing toothpastes, hard/acidic/salty foods, alcohol, and carbonated drinks 4
Special Considerations for Behçet's Syndrome
- 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
- Evidence-based alternative: Sucralfate suspension has demonstrated efficacy in RCT for oral and genital ulcers 1
Diagnostic Workup Before Treatment
- Blood tests to perform: Full blood count, coagulation studies, fasting blood glucose, HIV antibody, and syphilis serology to exclude contraindications and provide diagnostic clues 1
- Look for underlying causes: Screen for celiac disease, inflammatory bowel disease, nutritional deficiencies (iron, folates), immune disorders, and neutropenia 3, 5