What is the recommended treatment for a patient presenting with mouth ulcers, considering their overall medical history and potential underlying conditions?

Treatment of Mouth Ulcers

Start with topical corticosteroids as first-line therapy, selecting the formulation based on ulcer location and extent, then escalate to systemic therapy only for refractory or highly symptomatic cases. 1, 2

First-Line Topical Therapy

Topical Corticosteroids (Primary Treatment)

For localized, easily accessible ulcers:

• Apply clobetasol propionate 0.05% ointment mixed in equal amounts with Orabase directly to dried ulcer surfaces 2-4 times daily 1, 2, 3
• This provides the highest potency steroid for focal lesions 4, 1

For multiple or widespread ulcers:

• Use betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water as a rinse-and-spit preparation four times daily 1, 2, 3
• Alternative: dexamethasone mouth rinse (0.1 mg/ml) for difficult-to-reach locations 4, 1
• Alternative: fluticasone propionate nasules diluted in 10 mL water twice daily 3

Pain Management (Use Concurrently)

Topical anesthetics before meals:

• Benzydamine hydrochloride oral rinse or spray every 3 hours, particularly before eating 1, 2, 3
• Viscous lidocaine 2% applied 3-4 times daily for severe pain 1, 2, 3

Mucoprotectant barriers:

• Gelclair mucoprotectant gel applied three times daily to form protective coating 1, 2
• White soft paraffin ointment to lips every 2 hours if affected 1, 2

Oral Hygiene Measures

• Clean mouth daily with warm saline mouthwashes to reduce bacterial colonization 1, 2, 3
• Use antiseptic oral rinses twice daily: either 1.5% hydrogen peroxide or 0.2% chlorhexidine digluconate 1, 2, 3

Second-Line Therapy for Non-Responsive Ulcers

Intralesional Steroids

For persistent ulcers after 1-2 weeks of topical therapy:

• Intralesional triamcinolone injections weekly (total dose 28 mg) in conjunction with topical clobetasol 4, 1, 2, 3

Alternative Topical Immunomodulator

• Tacrolimus 0.1% ointment applied twice daily for 4 weeks for recalcitrant ulcers 1, 2, 3

Third-Line Systemic Therapy

Systemic Corticosteroids (For Highly Symptomatic or Recurrent Cases)

Reserve for severe, highly symptomatic, or recurrent ulcers:

• Prednisone/prednisolone 30-60 mg (or 1 mg/kg) for 1 week, followed by dose tapering over the second week 4, 1, 3
• Critical pitfall: Do not taper prematurely before disease control is established 1, 3

Systemic Immunomodulators (For Recurrent Aphthous Stomatitis ≥4 Episodes/Year)

First-line systemic agent:

• Colchicine as first-line systemic therapy, especially effective for patients with erythema nodosum or genital ulcers 1, 3, 5, 6

For resistant cases:

• Consider azathioprine, interferon-alpha, or TNF-alpha antagonists 1, 3
• Thalidomide is most effective but reserved only as alternative to oral corticosteroids due to toxicity 7, 5

Treatment of Secondary Infections

If candidal infection suspected (white coating, burning):

• Nystatin oral suspension 100,000 units four times daily for 1 week 2, 3
• Alternative: Miconazole oral gel 5-10 mL held in mouth after food four times daily for 1 week 2, 3

When to Refer or Escalate

Refer to specialist if:

• Ulcers persist beyond 2 weeks despite treatment 1
• Solitary chronic ulcer present (requires biopsy to exclude squamous cell carcinoma) 5
• Recurrent ulcers with systemic symptoms suggesting Behçet's disease, inflammatory bowel disease, or nutritional deficiencies 1, 8, 5

Adjunctive Measures

Dietary modifications:

• Avoid hard, acidic, salty foods, alcohol, and carbonated drinks 6
• Avoid toothpastes containing sodium lauryl sulfate 6

For dry mouth:

• Recommend sugarless chewing gum, candy, or salivary substitutes 1

Treatment Algorithm Summary

1. Start topical corticosteroids (clobetasol for localized, betamethasone rinse for widespread) + topical anesthetics + oral hygiene measures 1, 2, 3
2. If no improvement after 1-2 weeks: Add intralesional triamcinolone or switch to tacrolimus ointment 1, 2, 3
3. If highly symptomatic or recurrent (≥4 episodes/year): Add systemic corticosteroids (short course with taper) or colchicine 1, 3
4. If refractory to above: Consider azathioprine, interferon-alpha, or TNF-alpha antagonists 1, 3