What is the supportive management for a typical recurrent aphthous ulcer?

Supportive Management of Aphthous Ulcers

Start with topical corticosteroids as first-line therapy, selecting the formulation based on ulcer location, combined with pain control measures and barrier protection to reduce symptoms and accelerate healing. 1, 2

First-Line Topical Corticosteroid Therapy

The cornerstone of aphthous ulcer management is topical corticosteroid application, with formulation selection based on ulcer accessibility and distribution 1, 2:

• For localized, accessible ulcers: Apply clobetasol 0.05% gel or ointment directly to the dried ulcer 2-4 times daily 1, 2
• Alternative for localized lesions: Triamcinolone acetonide 0.1% paste applied to dried ulcer 2-4 times daily 1, 2
• For multiple or widespread ulcers: Use betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water as a rinse-and-spit solution 4 times daily 1, 2
• Alternative rinse option: Dexamethasone mouth rinse (0.1 mg/mL) used similarly 1, 2

The key technical point is applying these agents to dried mucosa to maximize adherence and contact time 1, 2.

Pain Management

Pain control is essential for maintaining nutrition and quality of life during ulcer episodes 1, 2:

• Viscous lidocaine 2%: Apply topically 3-4 times daily, particularly before meals 1, 2
• Benzydamine hydrochloride: Use as rinse or spray every 3 hours, especially before eating 1, 2
• Amlexanox 5% oral paste: Consider for severe pain as a topical NSAID option 1, 2

Barrier Protection and Oral Hygiene

These measures protect the ulcerated surface and reduce secondary infection risk 1, 2:

• Mucoprotectant mouthwashes (Gelclair or Gengigel): Apply 3 times daily to create a protective barrier over ulcerated mucosa 1, 2
• Warm saline rinses: Use daily to reduce bacterial colonization 1, 2
• Chlorhexidine digluconate 0.2%: Rinse twice daily as an antiseptic 1, 2

Dietary and Lifestyle Modifications

Avoiding irritants accelerates healing 3:

• Eliminate hard, acidic, and salty foods 3
• Avoid alcohol and carbonated drinks 3
• Switch to toothpaste without sodium lauryl sulfate 3

Escalation for Non-Responsive Ulcers

If ulcers fail to improve after 1-2 weeks of topical therapy, escalate treatment 1, 2:

• Intralesional triamcinolone: Inject weekly for persistent localized ulcers (total dose up to 28 mg) 1, 2
• Tacrolimus 0.1% ointment: Apply twice daily for 4 weeks as an alternative for recalcitrant ulcers 1, 2

Systemic Therapy for Recurrent Cases

For patients with recurrent aphthous stomatitis (≥4 episodes per year), systemic therapy is warranted 1, 2:

• Colchicine: Preferred first-line systemic agent for recurrent disease 1, 2, 3
• Systemic corticosteroids: For severe symptomatic cases, use prednisone/prednisolone 30-60 mg (or 1 mg/kg) for 1 week, then taper over the second week 1, 2

Critical Red Flags Requiring Further Action

Any ulcer persisting beyond 2 weeks mandates specialist referral and biopsy to exclude malignancy 1, 2, 4:

• Biopsy is mandatory for ulcers lasting >2 weeks 1, 4
• Investigate for underlying systemic conditions including complete blood count, iron, folate, B12 levels, celiac serology, and HIV testing if recurrent 1, 4
• Refer to specialist if ulcers don't respond to 1-2 weeks of treatment 2, 4

Common Pitfalls to Avoid

• Do not taper corticosteroids prematurely before disease control is established 2
• Do not rely solely on topical treatments for persistent ulcers without establishing a definitive diagnosis, as this delays identification of malignancy or systemic disease 4
• Do not overlook nutritional deficiencies (iron, B12, folate) as correctable underlying causes 4

Practical Treatment Algorithm

1. Initial presentation: Start topical corticosteroid (clobetasol for localized, betamethasone rinse for widespread) + lidocaine for pain + barrier agents 1, 2
2. Add: Saline rinses and chlorhexidine + dietary modifications 1, 2, 3
3. At 1-2 weeks if no improvement: Add intralesional triamcinolone or tacrolimus ointment 1, 2
4. For recurrent cases (≥4/year): Start colchicine as systemic maintenance therapy 1, 2
5. For severe refractory cases: Short course of systemic corticosteroids with proper taper 1, 2
6. If persists >2 weeks: Mandatory biopsy and systemic workup 1, 2, 4