Management of Aphthous Ulcers

First-Line Topical Therapy

The American College of Physicians recommends starting with topical corticosteroids as first-line therapy for all aphthous ulcers, selecting the formulation based on ulcer location and extent, and escalating to systemic therapy only for refractory or severe recurrent cases 1, 2, 3
For localized, accessible ulcers, apply clobetasol 0.05% gel or ointment directly to the dried ulcer 2-4 times daily 1, 2, 3
Alternatively, use triamcinolone acetonide 0.1% paste applied to the dried ulcer 2-4 times daily 1
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, 3
Dexamethasone mouth rinse (0.1 mg/mL) can be used as an alternative 1, 3

Apply viscous lidocaine 2% topically 3-4 times daily, particularly before meals 1, 2, 3
Use benzydamine hydrochloride rinse or spray every 3 hours, especially before eating 1, 2
Consider amlexanox 5% oral paste (topical NSAID) for severe pain 1

Apply mucoprotectant mouthwashes (Gelclair or Gengigel) 3 times daily to protect ulcerated mucosa 1, 2, 3
Rinse with warm saline mouthwashes daily to reduce bacterial colonization 1, 2
Use 0.2% chlorhexidine digluconate mouthwash twice daily as an antiseptic rinse 1, 2, 3

When topical therapy fails after 1-2 weeks, inject triamcinolone weekly (total dose up to 28 mg) for persistent localized ulcers 1, 2, 3
Consider tacrolimus 0.1% ointment applied twice daily for 4 weeks for recalcitrant ulcers 1, 2

For recurrent aphthous stomatitis (≥4 episodes per year) or highly symptomatic cases, colchicine is the preferred first-line systemic therapy 1, 2, 3
For severe cases, use prednisone/prednisolone 30-60 mg (or 1 mg/kg) for 1 week, then taper over the second week 4, 1, 2, 3

Refer to a specialist if ulcers persist >2 weeks despite treatment 1, 3
Biopsy is mandatory for ulcers lasting >2 weeks to rule out malignancy 1, 3
Investigate for underlying systemic conditions, such as obtaining complete blood count, nutritional studies (iron, folate, B12), celiac serology, and HIV testing if recurrent 1

Start with topical corticosteroids (clobetasol for localized, betamethasone rinse for widespread) + pain control (lidocaine, benzydamine) + barrier agents 1, 2, 3
Add oral hygiene measures (saline rinses, chlorhexidine) and dietary modifications 1, 2
If no improvement in 1-2 weeks, add intralesional triamcinolone or tacrolimus ointment 1, 2
For recurrent cases (≥4/year), start colchicine as systemic therapy 1, 2, 3
For severe refractory cases, use a short course of systemic corticosteroids with proper taper 4, 1, 2, 3