What is the initial management approach for a patient with an aphthous ulcer?

Treatment of Aphthous Ulcers

Start with topical corticosteroids as first-line therapy, combined with pain control measures and oral hygiene, escalating to systemic therapy only for refractory or severe cases. 1, 2

First-Line Topical Corticosteroid Therapy

The cornerstone of initial management is topical corticosteroid application, with selection based on ulcer location and extent 1, 2:

For localized, accessible ulcers:

• Apply clobetasol 0.05% gel or ointment directly to dried ulcer surface 2-4 times daily 1, 2
• Alternative: Clobetasol 0.05% ointment mixed in 50% Orabase applied twice weekly to dried mucosa 2, 3
• Alternative: Triamcinolone acetonide 0.1% paste applied directly to dried ulcer 2-4 times daily 1

For multiple or widespread ulcers:

• Use betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water as a rinse-and-spit solution 2-4 times daily 1, 2, 3
• Alternative: Dexamethasone 0.1 mg/mL mouth rinse 1
• Alternative: Fluticasone propionate nasules diluted in 10 mL water twice daily 2, 3

Pain Management (Concurrent with Steroids)

Implement pain control measures immediately alongside corticosteroid therapy 1, 2:

• Benzydamine hydrochloride rinse or spray every 3 hours, particularly before eating 1, 2
• Viscous lidocaine 2% applied 3-4 times daily for severe pain 1, 2
• Barrier preparations (Gelclair or Gengigel) applied three times daily for mucoprotection 1, 3
• Apply white soft paraffin ointment to lips every 2 hours 1

Oral Hygiene and Antiseptic Measures

Maintain rigorous oral hygiene to reduce bacterial colonization and secondary infection 1, 2:

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

Second-Line Therapy for Non-Responsive Ulcers

If ulcers persist after 1-2 weeks of topical therapy, escalate treatment 1, 3:

Intralesional corticosteroids:

• Triamcinolone injections weekly (total dose 28 mg) in conjunction with topical clobetasol 1, 3

Alternative topical immunomodulator:

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

Systemic Therapy for Severe or Recurrent Disease

Reserve systemic treatment for highly symptomatic ulcers or recurrent aphthous stomatitis (≥4 episodes per year) 1, 3:

First-line systemic therapy:

• Colchicine is particularly effective for recurrent aphthous stomatitis, especially when associated with erythema nodosum, genital ulcers, or Behçet's disease 1, 3, 4

Short-course systemic corticosteroids:

• Prednisone/prednisolone 30-60 mg (or 1 mg/kg) for 1 week, followed by tapering over the second week 1, 2, 3
• Pediatric dosing: 1-1.5 mg/kg/day up to maximum 60 mg 1

Third-line immunosuppressive therapy (for resistant cases):

• Azathioprine 2.5 mg/kg/day for severe cases with frequent recurrences 3
• Interferon-alpha or TNF-alpha antagonists 1, 3
• Thalidomide (most effective but limited by teratogenicity and peripheral neuropathy risks) 3, 4

Critical Pitfalls to Avoid

Do not taper corticosteroids prematurely before disease control is established 1, 2. This is a common error that leads to treatment failure.

Rule out secondary candidal infection before or during corticosteroid therapy 2, 3:

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

Biopsy any ulcer lasting >2 weeks or not responding to 1-2 weeks of treatment to exclude malignancy, especially squamous cell carcinoma 1, 5.

Identify and correct underlying causes before initiating treatment 6, 5:

• Nutritional deficiencies (iron, folate, B12)
• Celiac disease or inflammatory bowel disease
• HIV infection or neutropenia
• Behçet's disease

Avoid triggers 5:

• Sodium lauryl sulfate-containing toothpastes
• Hard, acidic, salty foods
• Alcohol and carbonated drinks