How should a new aphthous ulcer be managed in an otherwise healthy adult?

Management of New Aphthous Ulcer in Healthy Adults

Start with topical high-potency corticosteroids as first-line therapy, specifically betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water used as a rinse-and-spit solution 2-4 times daily, combined with topical anesthetics for pain control. 1, 2

First-Line Topical Therapy

Corticosteroid Options (Choose Based on Ulcer Location)

• 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 1-4 times daily 1, 2, 3
• For localized, accessible ulcers: Apply clobetasol 0.05% ointment mixed in 50% Orabase directly to dried ulcer surface 2-4 times daily 1, 2
• Alternative for widespread ulcers: Dexamethasone mouth rinse (0.1 mg/ml) or fluticasone propionate nasules diluted in 10 mL water twice daily 1, 2

Pain Management (Use Concurrently)

• Topical anesthetic: Viscous lidocaine 2% applied before meals, up to 3-4 times daily 1, 3
• Topical NSAID: Benzydamine hydrochloride rinse or spray every 3 hours, particularly before eating 1, 3
• Barrier protection: Apply Gelclair mucoprotectant gel three times daily to form protective coating over ulcerated surfaces 1, 3

Oral Hygiene Measures

• Clean mouth daily with warm saline mouthwashes to reduce bacterial colonization 1, 3
• Use antiseptic oral rinses twice daily (0.2% chlorhexidine digluconate or 1.5% hydrogen peroxide) 1, 3
• Apply white soft paraffin ointment to lips every 2 hours if affected 1, 3

Lifestyle Modifications

• Avoid hard, acidic, salty foods and carbonated drinks 4
• Avoid toothpastes containing sodium lauryl sulfate 4
• Avoid alcohol 4

When to Escalate Treatment

Indications for Second-Line Therapy

If the ulcer does not respond to 1-2 weeks of topical treatment, escalate to: 1

• Intralesional steroids: Triamcinolone injections weekly (total dose 28 mg) in conjunction with topical clobetasol 1, 2, 3
• Alternative topical agent: Tacrolimus 0.1% ointment applied twice daily for 4 weeks 2, 3

Indications for Systemic Therapy

For highly symptomatic or recurrent ulcers (≥4 episodes per year): 1, 2

• Short-course systemic corticosteroids: Prednisone/prednisolone 30-60 mg (or 1 mg/kg) for 1 week, followed by tapering over the second week 1, 2
• For recurrent aphthous stomatitis: Colchicine as first-line systemic therapy, particularly effective when associated with erythema nodosum or genital ulcers 1, 2, 5

Red Flags Requiring Specialist Referral

• Ulcer persisting beyond 2 weeks despite treatment 1
• Ulcer present for more than 2 weeks at initial presentation 1
• Solitary chronic ulcer (requires biopsy to exclude squamous cell carcinoma) 5
• Associated systemic symptoms suggesting underlying disease (inflammatory bowel disease, Behçet's disease, celiac disease, nutritional deficiencies) 5, 6

Critical Pitfalls to Avoid

• Do not taper corticosteroids prematurely before disease control is established 1
• Screen for secondary candidal infection before or during corticosteroid use; treat with nystatin oral suspension 100,000 units four times daily or miconazole oral gel 5-10 mL four times daily for 1 week if present 2, 3
• Do not assume all oral ulcers are benign aphthous ulcers—consider differential diagnoses including trauma, infections, drug-induced ulcers, and malignancy 5, 7

Treatment Efficacy Expectations

Betamethasone-based compounds achieve approximately 94% good-to-excellent clinical response rates in inflammatory oral conditions, with minimal systemic absorption when used as a rinse-and-spit preparation. 3 Treatment relieves pain, lessens functional impairment, and reduces frequency and severity of recurrences, though no curative therapy exists to prevent recurrence entirely. 4, 6