What is the first-line treatment for aphthous ulcers?

Treatment for Aphthous Ulcers

Start with topical corticosteroids as first-line therapy for aphthous ulcers, selecting the specific formulation based on ulcer location and extent. 1

First-Line Topical Corticosteroid Selection

The choice of topical steroid depends on whether ulcers are localized or widespread:

For localized, accessible ulcers:

• Apply clobetasol gel or ointment 0.05% directly to the dried ulcer 1
• Alternatively, use triamcinolone acetonide 0.1% paste applied directly to dried ulcer 2-4 times daily 1
• For more severe localized lesions, clobetasol 0.05% ointment mixed in 50% Orabase applied twice weekly to dried mucosa 1

For multiple or widespread ulcers:

• Use dexamethasone mouth rinse 0.1 mg/ml as a rinse-and-spit solution 1
• Alternatively, betamethasone sodium phosphate 0.5 mg dissolved in 10 ml water used as rinse-and-spit 2-4 times daily 1

Essential Adjunctive Pain Control

Pain management should be initiated alongside corticosteroids, not as an alternative:

• Apply viscous lidocaine 2% before meals for immediate pain relief 1
• Use benzydamine hydrochloride rinse or spray every 3 hours, particularly before eating 1
• For severe pain, apply amlexanox 5% oral paste (topical NSAID) 1, 2

Mucosal Protection and Oral Hygiene

Barrier preparations provide additional symptom relief:

• Apply mucoprotectant mouthwashes (e.g., Gelclair) three times daily 1
• Use white soft paraffin ointment to lips every 2 hours 1
• Clean mouth daily with warm saline mouthwashes 1
• Use antiseptic oral rinses twice daily (1.5% hydrogen peroxide or 0.2% chlorhexidine digluconate) 1, 3

Preventive Measures

Patients should avoid triggers that exacerbate ulceration:

• Eliminate toothpastes containing sodium lauryl sulfate 3
• Avoid hard, acidic, salty foods, alcohol, and carbonated drinks 3

Second-Line Treatment for Refractory Cases

When topical therapy fails after 1-2 weeks, escalate treatment:

Intralesional therapy:

• Triamcinolone injections weekly (total dose 28 mg) for persistent ulcers 1

Systemic corticosteroids for highly symptomatic cases:

• Prednisone/prednisolone 30-60 mg or 1 mg/kg for 1 week with tapering over the second week 1
• In children, dose at 1-1.5 mg/kg/day up to maximum 60 mg 1

For recurrent aphthous stomatitis (≥4 episodes per year):

• Colchicine as first-line systemic therapy, especially effective for patients with erythema nodosum or genital ulcers 1, 4, 2
• Consider azathioprine, interferon-alpha, or TNF-alpha inhibitors for resistant cases 1
• Thalidomide is the most effective treatment but use is limited by frequent adverse effects 4

Critical Pitfall to Avoid

Do not taper corticosteroids prematurely before disease control is established, as this leads to treatment failure and recurrence 1

When to Refer

Refer patients to a specialist for:

• Ulcers lasting more than 2 weeks 1
• Ulcers not responding to 1-2 weeks of treatment 1
• Consider biopsy for ulcers lasting over 2 weeks to exclude malignancy, particularly for solitary chronic ulcers 1, 4

Special Consideration for Behçet's Disease

If Behçet's syndrome is suspected (recurrent oral and genital ulcers):

• Start with topical corticosteroids 1
• Add colchicine for recurrent mucocutaneous involvement 1
• Progress to azathioprine, interferon-alpha, or TNF-alpha antagonists for refractory cases 1
• Sucralfate suspension has demonstrated efficacy in randomized controlled trials for oral and genital ulcers 1