What should I do to manage and treat my canker sores?

Management of Canker Sores (Aphthous Ulcers)

For canker sores, start with topical corticosteroid rinses—specifically betamethasone sodium phosphate 0.5 mg dissolved in 10 mL of water as a rinse-and-spit solution 1-4 times daily—as this is the first-line treatment recommended by dermatology guidelines. 1

First-Line Treatment Approach

Topical corticosteroids are the primary treatment:

• Betamethasone sodium phosphate 0.5 mg in 10 mL water used as a 2-3 minute rinse-and-spit solution one to four times daily is the preferred initial therapy 1
• Alternatively, fluticasone propionate nasules diluted in 10 mL water twice daily can be used 1
• For localized lesions, clobetasol 0.05% ointment mixed in 50% Orabase applied twice weekly to dried mucosa is highly effective 1

These corticosteroid options directly reduce inflammation and accelerate healing with minimal systemic absorption when used as directed. 2

Pain Management

For symptomatic relief while the ulcers heal:

• Barrier preparations such as Gengigel mouth rinse/gel or Gelclair provide immediate pain control by protecting exposed nerve endings 1
• Benzocaine topical products temporarily relieve pain associated with canker sores 3
• Follow the WHO pain management ladder for more severe pain, escalating from topical anesthetics to systemic analgesics as needed 1

Supportive Care Measures

Basic oral hygiene accelerates healing:

• Daily warm saline mouthwashes reduce bacterial colonization and promote healing 4
• Antiseptic rinses (0.2% chlorhexidine or 1.5% hydrogen peroxide) twice daily prevent secondary infection 4
• Apply white soft paraffin ointment to lips every 2 hours if cracking occurs 4

When First-Line Treatment Fails

For recalcitrant ulcers not responding to topical corticosteroids within 7 days: 3

• Tacrolimus 0.1% ointment applied twice daily for 4 weeks is the second-line option 1
• Intralesional triamcinolone (total dose 28 mg weekly) combined with topical clobetasol gel 0.05% for persistent lesions 1

Severe or Recurrent Cases

For highly symptomatic or frequently recurring canker sores:

• Systemic corticosteroids: High-dose pulse therapy with 30-60 mg (or 1 mg/kg) oral prednisone/prednisolone for 1 week, followed by dose tapering over the second week 1
• Colchicine is particularly effective for recurrent aphthous stomatitis, especially when associated with Behçet disease 1
• Azathioprine 2.5 mg/kg/day for severe cases with frequent recurrences 1
• Colchicine combined with topical treatments is recommended for recurrent disease 1

Critical Pitfalls to Avoid

Watch for secondary candidal infection:

• Patients on corticosteroid therapy are at risk for concurrent candidiasis 1
• Treat with nystatin oral suspension or miconazole oral gel if white patches or burning develop 1, 4

Seek medical attention if:

• Symptoms do not improve within 7 days 3
• Irritation, pain, or redness persists or worsens 3
• Swelling, rash, or fever develops 3
• Ulcers are unusually large (>1 cm), last longer than 3 weeks, or are associated with systemic symptoms—these may indicate Behçet disease or other serious conditions requiring systemic evaluation 5