What is the appropriate topical medication for an oral ulcer?

Topical Treatment for Oral Ulcers

For oral ulcers, apply clobetasol 0.05% ointment mixed in 50% Orabase twice weekly to localized lesions on dried mucosa, or use betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water as a 2-3 minute rinse-and-spit solution one to four times daily for more widespread involvement. 1

First-Line Topical Corticosteroid Options

The choice of topical corticosteroid depends on the distribution and severity of oral ulceration:

For Localized Ulcers

• Clobetasol 0.05% ointment mixed in 50% Orabase applied twice weekly to dried mucosa is the most potent option for isolated lesions 2, 1
• The patient can mix this preparation at home and store it in the refrigerator 2
• Triamcinolone acetonide 0.1% in adhesive paste (Adcortyl in Orabase) applied directly to the lesion is an alternative for isolated ulcers 2

For Multiple or Widespread Ulcers

• Betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water used as a 2-3 minute rinse-and-spit solution one to four times daily is most practical 2, 1
• Fluticasone propionate nasules diluted in 10 mL water twice daily is an alternative mouthwash option 2, 1
• Asthma inhalers can be sprayed directly on lesions: beclomethasone dipropionate 50-200 μg or budesonide 50-200 μg 2

Pain Management Adjuncts

Pain control is essential for maintaining oral intake and quality of life:

• Benzydamine hydrochloride 0.15% (Difflam Oral Rinse) used before eating or toothbrushing provides topical anesthesia 2
• Barrier preparations such as Gengigel mouth rinse/gel or Gelclair help with pain control 2, 1
• Follow the WHO pain ladder for more severe pain requiring systemic analgesia 1

Oral Hygiene Measures

Maintaining oral hygiene prevents secondary infection and dental complications:

• Use chlorhexidine gluconate 0.2% (Corsodyl), hexetidine 0.1% (Oraldene), or 1:4 hydrogen peroxide solutions as antiseptic mouthwashes 2
• Employ soft toothbrushes to minimize trauma 2
• Follow a soft diet to reduce mechanical irritation 2

Second-Line Topical Agents for Recalcitrant Cases

When first-line corticosteroids fail:

• Tacrolimus 0.1% ointment applied twice daily for 4 weeks is equally effective as triamcinolone acetonide 0.1% paste 2, 1
• Note that mouthwashes may need 50% dilution to reduce discomfort 2
• Topical ciclosporin (100 mg/mL) 5 mL used three times daily can be effective but tastes unpleasant and is expensive 2

Intralesional Therapy for Persistent Ulcers

For ulcers that don't respond to topical treatment:

• Weekly intralesional triamcinolone (total dose 28 mg) in conjunction with topical clobetasol gel or ointment (0.05%) can achieve faster clinical remission 2, 1

Critical Pitfalls to Avoid

• Screen for and treat concurrent candidal infection with nystatin oral suspension or miconazole oral gel, as patients on topical corticosteroids are susceptible to oral candidiasis 2, 1
• Apply topical corticosteroids during the prodromal phase of ulceration (when lymphocyte activity is maximal) for maximum efficacy 3
• For any solitary chronic ulcer lasting more than 2-3 weeks, biopsy is mandatory to rule out squamous cell carcinoma 4
• Ensure proper application technique: for ointments mixed with Orabase, the mucosa should be dried first for optimal adherence 2

When to Escalate to Systemic Therapy

Consider systemic corticosteroids for highly symptomatic or recurrent ulcers:

• High-dose pulse therapy: 30-60 mg or 1 mg/kg oral prednisone/prednisolone for 1 week followed by dose tapering over the second week 1
• For recurrent aphthous stomatitis with frequent recurrences (≥4 times per year), colchicine combined with topical treatments is particularly effective 1, 4