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Individual primers on more than 100 skin diseases including initial evaluation, treatment options, and clinical case studies.
Recurrent aphthous ulcers are the most common oral ulcerative ailment, which classically appear as shallow, round or oval ulcers with an inflammatory edge and a faint pseudomembrane. Treatment is based on limited evidence and focused on symptomatic relief and decreasing ulcer duration, generally with local or topical analgesics or anti-inflammatory medications. The most common form of recurrent aphthous stomatitis is characterized by minor aphthous ulcers, which comprise about 80% of cases of recurrent aphthous stomatitis. Therapy for oral ulcerations is aimed at providing symptomatic relief and promoting ulcer healing.
There is an important differential diagnosis when evaluating patients with oral ulcers, even if the history and exam is strongly suggestive of aphthous ulcerations.
First-line therapy: Patients with active ulcers should avoid trauma to the oral mucosa (including hard toothbrushes or sharp foods) and limit intake of acidic products which can worsen pain.
Topical anesthetics (0.15% benzydamine oral rinse, 2-5% lidocaine gel) may be applied to ulcers four times daily for two weeks or until ulcers heal to relieve pain.
Protective films, such as carmellose or Orabase, may be applied to the ulcers to diminish discomfort. Antimicrobial rinses (chlorhexidine gluconate, triclosan) may decrease bacterial plaques and limit outbreaks in some patients. Patients may be counseled to avoid foods that may trigger or worsen eruptions, such as nuts, acidic foods or drinks, salty meals, and alcohol. In certain cases physicians may opt to order lab tests to evaluate for nutritional deficiencies or rarer underlying causes of oral ulcerations.
Thalidomide 100 mg daily may reduce ulcer outbreak and can offer significant symptomatic relief to patients who suffer from major aphthous ulcers.
Using topical steroids for prolonged periods in the mouth can predispose to oral candidiasis. Any oral mucosal ulcer which fails to heal after three or four weeks warrants evaluation and possible biopsy to rule out malignancy.
Aphthae are diagnosed by history and physical exam alone; there is a broad differential for diseases which can manifest with oral ulcerations, and extended work-up is indicated if there are signs or symptoms of a systemic process.
Any ulcer which fails to heal after three or four weeks warrants evaluation and possible biopsy; this may be managed by a dermatologist or an oral medicine physician.

Widespread oral erosions, or oral erosions accompanied by cutaneous bullae, should prompt consideration for a mucocutaneous disorder such as pemphigus or a severe drug eruption. If the diagnosis is uncertain or there are systemic symptoms suggestive of a more widespread process, referral to a specialist may be appropriate. DISCLAIMER: Use of this Website constitutes acceptance of the Derm101 terms of use and privacy policy. The differential diagnosis can include oral involvement of inflammatory bowel disease, gluten sensitivity, Behcet’s syndrome, herpes simplex virus infection, other infections including syphilis, gonorrhea, coxsackievirus infection (hand-foot-mouth disease), and other herpes viruses (CMV, EBV, and VZV), HIV (including acute seroconversion), oral lichen planus, autoimmune blistering diseases, or drug eruptions. Topical analgesics and local protective topical medicaments may provide symptomatic relief.
Oral hygiene products containing sodium lauryl sulfate may trigger oral ulcers in some patients as well. If local methods fail, physicians should revisit the differential diagnosis and consider extended workup for mimics of aphthous ulcers. This may include evaluation of vitamins including iron, ferritin, total iron-binding capacity, folate, vitamin B levels, zinc, and magnesium, and evaluation of a complete blood count. Patients with severe recurrent aphthous stomatitis often require systemic therapies to control disease. These are generally drugs that target neutrophils (colchicine, dapsone) or TNF (pentoxifylline, infliximab, or etanercept).
Long-term use of local steroids can lead to systemic absorption when applied to the mucosa, particularly when the surface is ulcerated.
This site is intended for use by physicians and other healthcare providers for informational purposes only. The ulcers preferentially affect nonkeratinized mucosal surfaces, such as the labial or buccal mucosa, the sublingual mouth, or the tongue. Major aphthous ulcers are less common, making up 10-15% of cases, but often are more symptomatic and may require more aggressive treatment. Any ulcer that lasts for more than three or four weeks requires evaluation to rule out other serious diseases, including local malignancies. Depending on the patient’s history and review of systems, further testing for systemic diseases may be indicated, which could include antinuclear antibody and antineutrophilic cytoplasmic antibody levels, tissue transglutaminase antibodies, local or serological viral testing, gastroenterological evaluation, and more. Oral prednisone (30-60 mg daily) tapered over a two-week course may help heal ulcers more rapidly.

Due to the potential for serious adverse effects (teratogenicity, deep vein thrombosis, and neuropathy), thalidomide use is tightly regulated by the US government (requiring patients and prescribers to be part of the national STEPS registry program).
The content of this Website is NOT a substitute for medical advice from a qualified health care provider. Antimicrobial rinses may reduce the number of outbreaks and increase disease-free periods between ulcerations. The first lesions generally begin in childhood, and recurrent aphthous ulcers are more common in women, people under 40, Caucasian patients, nonsmokers, and people of high socioeconomic status.
A third type of aphthous stomatitis is termed herpetiform ulceration (although it is unrelated to herpes virus infection), and is characterized by multiple, pinpoint ulcerations. Gel-based topical are the easiest to apply and tend to be better tolerate than other vehicles. Approximately 80% of patients suffer from minor aphthae; major and herpetiform ulcerations are more likely to prompt patients to seek treatment, as they may last for weeks with significant discomfort.
Topical medicaments may be compounded in alternative vehicles, such as pastes (Orabase, Iso-Dent) to improve adherence to the moist mucosal surfaces.
The true prevalence is difficult to say, as aphthous ulcerations are likely underreported; on average the prevalence in the US is estimated to be about 20%.
Amlexanox paste is an anti-inflammatory topical which can improve healing and reduce ulcer size.
The diagnosis is generally made by history and physical exam alone, though the presence of systemic symptoms may prompt a more comprehensive investigation.
Most of the therapies discussed herein are not FDA approved for this indication; 1% triamcinolone dental paste is approved for relief of inflammatory conditions in the mouth, and 5% amlexanox paste is approved specifically for aphthous ulcerations. A history of recurrent oral mucosal ulcers, generally starting in childhood, and the typical small round or oval ulcers on exam are key.
There is likely an underlying genetic predisposition leading to immunologic abnormalities causing the inflammation in the oral cavity.
Systemic and local factors may play a role as well, with deficiencies of vitamins (iron, vitamin B, folate), oral trauma, anxiety or stress, food sensitivities, and hormonal changes suggested as possible triggers in subsets of patients, though overall the data is conflicting and there is scarce evidence suggesting a specific cause.

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