What is the first‑line treatment for a patient with oral ulcers (minor aphthous ulcers, traumatic lesions, or early recurrent aphthous stomatitis)?

Management of Oral Ulcers (Minor Aphthous Ulcers, Traumatic Lesions, Early Recurrent Aphthous Stomatitis)

Start with topical corticosteroids as first-line therapy for oral ulcers, selecting the specific formulation based on whether the lesions are localized or widespread. 1

First-Line Topical Corticosteroid Selection

For localized, accessible ulcers:

• Apply clobetasol gel or ointment 0.05% directly to the dried ulcer surface 2-4 times daily 1
• Alternatively, use triamcinolone acetonide 0.1% paste applied directly to dried ulcer 2-4 times daily 1

For multiple or widespread ulcers:

• Use dexamethasone mouth rinse (0.1 mg/ml) as a rinse-and-spit preparation 1
• Alternatively, dissolve betamethasone sodium phosphate 0.5 mg in 10 ml water and use as rinse-and-spit four times daily 1

Concurrent Pain Management (Essential Adjunct)

Add topical anesthetics to improve function and quality of life:

• Viscous lidocaine 2% applied before meals 1
• Benzydamine hydrochloride rinse or spray every 3 hours, particularly before eating 1
• For severe pain, consider amlexanox 5% oral paste (topical NSAID) 1, 2

Barrier Protection and Oral Hygiene

Apply mucoprotectant measures alongside steroids:

• Gelclair or Gengigel mouthwash/gel three times daily for mucosal protection 1
• White soft paraffin ointment to lips every 2 hours 1
• Daily warm saline mouthwashes for oral hygiene 1
• Antiseptic oral rinses (0.2% chlorhexidine digluconate or 1.5% hydrogen peroxide) twice daily 1

When to Escalate Beyond First-Line Therapy

Progress to intralesional triamcinolone injections (weekly, total dose 28 mg) if ulcers fail to respond to 1-2 weeks of topical therapy 1

For highly symptomatic or recurrent cases unresponsive to topical and intralesional approaches:

• Systemic corticosteroids: prednisone/prednisolone 30-60 mg (or 1 mg/kg) for 1 week, then taper over the second week 1
• Colchicine as first-line systemic therapy for recurrent aphthous stomatitis (≥4 episodes per year), especially effective when erythema nodosum or genital ulcers coexist 1, 3, 4

Critical Red Flags Requiring Specialist Referral

Refer to oral medicine specialist immediately if:

• Ulcer persists >2 weeks despite appropriate treatment 1, 5
• No response after 1-2 weeks of first-line therapy 1, 5
• Atypical morphology (stellate shape, undermined edges, induration) suggesting tuberculosis, malignancy, or autoimmune disease 6, 5
• Solitary chronic ulcer requiring biopsy to exclude squamous cell carcinoma 5, 3

Pre-Referral Laboratory Workup (If Ulcers Persist)

Before biopsy or specialist evaluation, obtain:

• Complete blood count (to detect anemia, leukemia, neutropenia) 6, 5
• Coagulation profile (to identify biopsy contraindications) 6, 5
• Fasting blood glucose (diabetes predisposes to fungal infections) 6, 5
• HIV antibody test 6, 5
• Syphilis serology 6, 5

Common Pitfalls to Avoid

• Do not taper corticosteroids prematurely before disease control is established 1
• Do not rely solely on topical treatments for ulcers persisting beyond 2 weeks without establishing a definitive diagnosis through biopsy 5
• Do not perform inadequate biopsies (small or superficial specimens miss diagnostic features) 6, 5
• Do not overlook systemic causes such as inflammatory bowel disease, Behçet's syndrome, bullous diseases, or hematologic malignancies in recurrent or refractory cases 6, 5