From the Guidelines
As a third-line treatment for severe aphthous ulcers in an adult patient, I would prescribe systemic corticosteroids, specifically oral prednisone/prednisolone 30–60 mg or 1 mg/kg for 1 week followed by dose tapering over the second week, as suggested by expert opinion 1. This approach is based on the expert opinion recommendations for targeted therapy-associated stomatitis, which can be applied to the treatment of severe aphthous ulcers. The use of systemic corticosteroids is recommended for highly symptomatic ulcers and for recurrent ulcers or oesophageal lesions, to bring symptoms under control quickly. Some key points to consider when prescribing systemic corticosteroids for severe aphthous ulcers include:
- The dose and duration of treatment should be tailored to the individual patient's needs and response to treatment
- The patient should be monitored closely for side effects, such as gastrointestinal upset, mood changes, and increased risk of infection
- The patient should be advised to maintain good oral hygiene and avoid spicy or acidic foods to help manage symptoms and promote healing
- Regular follow-up appointments should be scheduled to evaluate treatment response and adjust the treatment plan as needed. It's worth noting that, according to the expert opinion, other treatments such as coating agents, topical analgesic or anti-inflammatory agents, topical anesthetics, and alternative mouthwashes may be considered to treat stomatitis, but systemic corticosteroids are the recommended third-line treatment for severe cases 1.
From the Research
Third Line Treatment for Aphthous Ulcers
As a doctor, when an adult patient presents with a severe case of aphthous ulcers, the primary goal is to manage the symptoms and prevent recurrence. The following are potential third line treatment options:
- Thalidomide: This medication has been shown to be effective in extending the recurrence interval of continuous RAU 2. It is also effective in healing aphthous ulceration of the esophagus in patients infected with HIV 3.
- Systemic medications: These can be tried if topical therapy is ineffective. Levamisole has shown variable efficacy in reducing ulcer frequency and duration in patients with minor RAU 4.
- Oral corticosteroids: These should be reserved for severe cases of major RAU that do not respond to topical agents 4.
Considerations for Third Line Treatment
When considering third line treatment options, it is essential to weigh the potential benefits and risks of each medication. Thalidomide, for example, has been associated with adverse reactions such as somnolence, constipation, and rash 5. Additionally, it is contraindicated in pregnant women, women of childbearing age, and sexually active men not using contraception 5.
Potential Medications
Some potential medications that may be prescribed as third line treatment for aphthous ulcers include: