What is the appropriate treatment for a patient presenting with throat ulcers?

Treatment of Throat Ulcers

Begin with topical corticosteroids and pain control as first-line therapy for throat ulcers, progressing to systemic treatments only for refractory cases after establishing the underlying cause. 1

Immediate First-Line Management

Topical Corticosteroids

• Apply betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water as a rinse-and-spit solution 2-4 times daily for widespread or difficult-to-reach throat ulcers. 1, 2 This is the preferred formulation for pharyngeal involvement where direct application is impractical.
• For more accessible posterior oral/throat lesions, use dexamethasone mouth rinse (0.1 mg/mL) as an alternative. 1
• Fluticasone propionate nasules diluted in 10 mL water twice daily can also be effective. 2

Pain Management

• Use benzydamine hydrochloride rinse or spray every 3 hours, particularly before eating, to facilitate swallowing. 1, 3
• Apply viscous lidocaine 2% topically before meals for severe pain. 1
• Follow the WHO pain ladder for escalating analgesia if topical measures are insufficient. 2
• Consider oral acetaminophen for systemic pain relief at appropriate dosing. 3

Mucosal Protection and Hygiene

• Apply mucoprotectant mouthwashes (e.g., Gelclair, Gengigel) three times daily to create a protective barrier. 1, 2
• Perform daily warm saline mouthwashes to reduce bacterial colonization. 1, 3
• Use antiseptic oral rinses twice daily (1.5% hydrogen peroxide or 0.2% chlorhexidine digluconate). 1

Second-Line Management for Refractory Cases

When to Escalate

Escalate therapy if ulcers persist beyond 2 weeks or fail to respond to 1-2 weeks of topical treatment. 1, 3 At this point, specialist referral and biopsy should be considered to exclude malignancy or systemic disease. 4, 1

Systemic Corticosteroids

• Administer prednisone/prednisolone 30-60 mg (or 1 mg/kg) daily for 1 week, followed by tapering over the second week for highly symptomatic or recurrent ulcers. 1, 2 This is appropriate when topical therapy fails and infectious causes have been excluded.
• Avoid premature tapering before disease control is established. 1, 2

Alternative Systemic Therapies

• Consider colchicine as first-line systemic therapy for recurrent aphthous ulcers (≥4 episodes per year), especially if associated with erythema nodosum or genital ulcers. 1, 2 This is particularly effective in Behçet's disease. 2
• For severe refractory cases, azathioprine 2.5 mg/kg/day, interferon-alpha, or TNF-alpha inhibitors may be warranted. 1, 2

Critical Diagnostic Considerations

Rule Out Serious Causes First

• Obtain biopsy for any ulcer lasting over 2 weeks or not responding to treatment to exclude squamous cell carcinoma or systemic disease. 4, 1 Throat ulcers can mimic benign lesions while harboring malignancy. 5
• Perform blood tests including complete blood count, coagulation studies, fasting glucose, HIV antibody, and syphilis serology before biopsy. 1
• Exclude cytomegalovirus infection in immunocompromised patients or steroid-refractory cases. 4
• Test for Clostridium difficile if the patient has concurrent gastrointestinal symptoms or recent antibiotic exposure. 4

Key History Elements

• Duration of ulcers and frequency of recurrence. 4, 5
• Recent viral illness, trauma, or new medication exposure. 3, 5
• Presence of skin, genital, or ocular lesions suggesting systemic disease (Behçet's, pemphigus, Stevens-Johnson syndrome). 4, 5
• Constitutional symptoms including fever, weight loss, or dysphagia. 5
• Immunosuppression, malnutrition, or other comorbidities. 4, 3

Common Pitfalls to Avoid

• Never use topical corticosteroids for suspected viral (herpes simplex, CMV) or bacterial infections, as this will worsen the condition. 3 Establish the diagnosis first.
• Do not delay surgical consultation beyond 7-10 days of ineffective medical therapy, as prolonged corticosteroid use without benefit increases morbidity. 4 This is particularly critical in severe cases.
• Avoid ciclosporin in patients with neurological symptoms due to neurotoxicity risk. 1
• Do not use topical lidocaine excessively in young children due to systemic absorption risk. 3
• Recognize that most throat infections are viral and self-limiting; antibiotics are rarely indicated unless bacterial superinfection is documented. 6

Special Populations

Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis

• Implement aggressive topical measures including steroids, anesthetics, and antiseptics for oral involvement. 1
• Consider systemic therapy for severe cases. 1

Behçet's Syndrome

• Start with topical steroids and colchicine. 1, 2
• Progress to azathioprine, interferon-alpha, or TNF-alpha antagonists for refractory mucocutaneous disease. 1, 2
• Sucralfate suspension has demonstrated efficacy in randomized trials. 1

Ulcerative Colitis with Oral Manifestations

• Treat the underlying inflammatory bowel disease with appropriate systemic therapy. 4
• Provide supportive care with nutritional support if malnourished. 4