Treatment of Aphthous Ulcers on the Inner Lip
For aphthous ulcers on the inner lip, start with topical corticosteroid therapy using betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water as a rinse-and-spit solution 1-4 times daily, or apply clobetasol 0.05% ointment mixed in 50% Orabase twice daily directly to dried lesions. 1
Algorithmic Treatment Approach
Step 1: First-Line Topical Corticosteroids
Choose based on ulcer characteristics:
For multiple ulcers or widespread involvement: Use betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water, hold in mouth for 2-3 minutes, then spit out 1-4 times daily 1
For isolated, localized ulcers: Apply clobetasol 0.05% ointment mixed in 50% Orabase twice daily to the dried mucosa 1
Alternative option: Fluticasone propionate nasules diluted in 10 mL water twice daily 1
The evidence strongly supports topical corticosteroids as first-line therapy, with multiple guidelines and a high-quality randomized controlled trial demonstrating significant reduction in ulcer size (7.17 mm² vs 4.35 mm² in placebo, p<0.001) and pain scores, with an 83% healing rate versus 55% for placebo 2. Importantly, serum dexamethasone levels remained undetectable after topical use, confirming safety 2.
Step 2: Pain Management (Concurrent with Corticosteroids)
Apply benzydamine hydrochloride 0.15% oral rinse or spray every 2-4 hours, particularly before eating 3
For severe pain interfering with eating: Use topical 2.5% lidocaine ointment sparingly applied directly to the ulcer 3
Barrier preparations: Consider Gengigel mouth rinse/gel or Gelclair for additional pain control 1
Step 3: Supportive Oral Care
Rinse with warm saline mouthwashes daily to reduce bacterial colonization 3
Avoid alcohol-containing mouthwashes as they exacerbate pain and delay healing 3
Apply white soft paraffin ointment to lips every 2 hours to protect the ulcer and maintain moisture 3
Use soft-bristled toothbrush with mild fluoride toothpaste twice daily 4
Avoid hard, acidic, salty foods and sodium lauryl sulfate-containing toothpastes 5
Step 4: Second-Line Treatment for Refractory Ulcers (No Improvement After 1-2 Weeks)
Apply tacrolimus 0.1% ointment twice daily for 4 weeks 1
Consider intralesional triamcinolone (total dose 28 mg weekly) combined with topical clobetasol 0.05% for persistent lesions 1
Step 5: Systemic Therapy for Severe or Highly Symptomatic Cases
Oral prednisone/prednisolone 30-60 mg (or 1 mg/kg) for 1 week, then taper over the second week 1
This approach is reserved for highly symptomatic ulcers that significantly impair eating or quality of life 1
Critical Pitfall: Rule Out Candidal Superinfection
If ulcers worsen or fail to respond to corticosteroids, treat concurrent candidal infection with nystatin oral suspension or miconazole oral gel before continuing corticosteroid therapy 1. Patients using topical corticosteroids are susceptible to oral candidiasis, which must be addressed 6.
Treatment Duration and Monitoring
Continue topical corticosteroids for 1-2 weeks or until ulcer resolution 3
If no improvement after 2 weeks, reevaluate the diagnosis and patient compliance 4
Most minor aphthous ulcers heal within 7-14 days with appropriate treatment 7, 5
Special Consideration for Recurrent Aphthous Stomatitis
If ulcers recur 4 or more times per year, this constitutes recurrent aphthous stomatitis (RAS) and requires investigation for underlying causes including celiac disease, inflammatory bowel disease, nutritional deficiencies (iron, folate), or Behçet's disease 7. For confirmed RAS, colchicine combined with topical treatments is the recommended systemic approach 1, 7.