What is the appropriate treatment for aphthous ulcers?

Treatment of Aphthous Ulcers

Begin with topical corticosteroids as first-line therapy, specifically clobetasol gel or ointment 0.05% applied directly to dried lesions twice daily for localized ulcers, or betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water as a rinse-and-spit solution four times daily for multiple or widespread ulcers. 1, 2, 3

First-Line Topical Therapy

Topical corticosteroids are the cornerstone of initial management and should be selected based on ulcer location and extent 1:

• For localized, accessible ulcers: Apply clobetasol gel or ointment 0.05% directly to dried mucosa twice daily 1, 2, 3
• For multiple or widespread ulcers: 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 1, 2
• Alternative steroid option: Triamcinolone acetonide 0.1% paste applied directly to dried ulcer 2-4 times daily 1
• Alternative rinse option: Dexamethasone mouth rinse (0.1 mg/mL) for difficult-to-reach areas 1

Clinical trials demonstrate that dexamethasone ointment significantly reduces ulcer size (7.2 mm² vs 4.3 mm² reduction) and pain levels compared to placebo, with an 83% healing rate versus 55% in controls, without detectable systemic absorption 4.

Pain Management

Implement aggressive pain control to maintain oral intake and quality of life 3:

• Topical anesthetics: Viscous lidocaine 2% applied before meals 3-4 times daily 1, 3
• Benzydamine hydrochloride: Rinse or spray every 3 hours, particularly before eating 1, 3
• Barrier preparations: Apply Gelclair or Gengigel mouth rinse/gel three times daily for mucosal protection 1, 2
• For severe pain: Follow the WHO pain management ladder with systemic analgesics as needed 2

Supportive Oral Hygiene Measures

Daily oral hygiene is essential to reduce bacterial colonization and promote healing 1, 3:

• Clean the mouth daily with warm saline mouthwashes 1, 3
• Use antiseptic oral rinses such as 0.2% chlorhexidine digluconate mouthwash twice daily 1, 3
• Apply white soft paraffin ointment to lips every 2 hours if affected 1
• For dry mouth, recommend sugarless chewing gum, candy, or salivary substitutes 1

Second-Line Treatment for Refractory Cases

If ulcers do not respond to topical therapy after 1-2 weeks, escalate treatment 1, 2:

• Intralesional steroids: Triamcinolone injections weekly (total dose 28 mg) in conjunction with topical clobetasol 1, 2, 3
• Tacrolimus ointment: 0.1% applied twice daily for 4 weeks as an alternative to triamcinolone 1, 2
• Systemic corticosteroids: Prednisone/prednisolone 30-60 mg or 1 mg/kg for 1 week with tapering over the second week for highly symptomatic or recurrent ulcers 1, 2, 3

Systemic Therapy for Recurrent Aphthous Stomatitis

For patients with recurrent ulcers (≥4 episodes per year), colchicine is the first-line systemic therapy 1, 2:

• Colchicine is particularly effective for recurrent aphthous stomatitis, especially when associated with erythema nodosum, genital ulcers, or Behçet's disease 1, 2, 5
• For severe cases with frequent recurrences: Azathioprine 2.5 mg/kg/day 2
• For refractory cases: Consider interferon-alpha or TNF-alpha inhibitors 1
• Thalidomide is the most effective treatment but should be reserved as an alternative to oral corticosteroids due to teratogenicity and peripheral neuropathy risks 2, 6, 5

Critical Red Flags and When to Refer

Refer to a specialist if ulcers persist beyond 2 weeks or do not respond to 1-2 weeks of treatment, as biopsy is warranted to exclude malignancy 1, 3:

• Every solitary chronic oral ulcer should be biopsied to rule out squamous cell carcinoma 5
• Blood tests (full blood count, coagulation, fasting blood glucose, HIV antibody, syphilis serology) should be performed before biopsy to exclude contraindications and provide diagnostic clues 1

Common Pitfalls to Avoid

• Do not prematurely taper corticosteroids before disease control is established 1, 3
• Treat concurrent candidal infection with nystatin oral suspension or miconazole oral gel before or during corticosteroid therapy 2
• Avoid sodium lauryl sulfate-containing toothpastes, hard, acidic, and salty foods, alcohol, and carbonated drinks 7
• If NSAID-induced: Stop the offending medication immediately and do not restart or switch to another traditional NSAID without considering cross-reactivity risk 3