Aphthous Ulcer (Recurrent Aphthous Stomatitis) — Treatment

Minor aphthous ulcers — labial mucosa and ventral tongue

Types (Classify First, Then Treat)

Treatment (Severity-Based)

Mild / Infrequent Minor Ulcers

• Symptomatic management — requires little else
• Chlorhexidine rinses — help maintain hygiene and reduce duration
• OTC topical protectants and analgesics (e.g., benzocaine-containing preparations)
• Compounded rinses containing combinations of topical steroids, antifungals, and local anesthetics (especially for odynophagia)

Moderate — When Treatment Is Necessary

• Topical corticosteroids — the general mainstay of treatment (e.g., triamcinolone acetonide in orabase, fluocinonide gel)
• Topical analgesics / anti-inflammatory agents — used in conjunction with steroids

Severe / Continuous Outbreaks / Major Aphthae

• Systemic corticosteroids (short-term) — effective for severe or continuous outbreak series
• Intralesional steroid injection — useful for larger (major) aphthae or lesions unresponsive to topical therapy

Refractory / Immunocompromised (HIV)

• Thalidomide 200 mg/day — shown to be effective for treatment (note: not effective for prevention of recurrence)
• Systemic immunosuppressives — second-line options include:
  • Azathioprine
  • Colchicine
  • Pentoxifylline
  • Dapsone
  • TNF-α antagonists

Special Considerations

• In HIV/immunocompromised patients: ulcers are more severe, deeper, more painful; may coalesce; serve as a marker for HIV disease progression. Monitor body weight and provide liquid nutritional supplements.
• Major aphthae: always biopsy the edge to rule out lymphoma or SCC before initiating treatment.
• Tobacco use has a negative association with aphthous ulcers (i.e., smokers have lower rates — but this does NOT suggest tobacco as treatment).
• Aphthous ulcers have no vesicular phase — this distinguishes them from herpes simplex lesions, which occur on keratinized mucosa.