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Practical lowdown

Traumatic and aphthous ulcers

Aphthous ulcers

Aphthous ulcers may be associated with stress, menstruation, poor overall health or, occasionally, coeliac disease.

Large single ulcers can reach 1-2cm in

diameter and take six weeks to heal, but at three weeks some improvement should

already be seen.

• Check FBC, iron, B12 and folate levels. Some 20 per cent of patients with

recurrent ulcers have low iron, B12 or

folate levels.

• Where ulceration is recurrent, check HIV status and endomysial antibodies.

Topical steroids

In milder cases give:

• triamcinolone in cellulose paste, thinly applied two to four times a day

• hydrocortisone pellets – dissolve one

pellet slowly in contact with the ulcer, three to four times a day.

In more severe cases, consider:

• betamethasone 0.5mg tablets dissolved in 15ml of water taken as a mouth rinse four times a day

• pressurised steroids (asthma inhalers) sprayed directly onto the ulcer (unlicensed use).

When to refer

• Refer if there are any other symptoms (such as uveitis, genital ulceration, arthritis) suggestive of a systemic disease.

• If there is continuous aphthous ulceration or severe ulceration refer to an oral medicine specialist. These patients may

benefit from higher-strength steroids or immunosuppressants including thalidomide.

Traumatic ulcers

• Treat the cause.

• Try a local anti-inflammatory agent, such as salicylate cream, applied three to four times a day.

• Refer for biopsy any ulcer that has not healed within three weeks after the removal of any local cause. It may be a squamous cell carcinoma.

This is an extract from Practical General Practice 5e, ISBN 07506 8867X, Elsevier Ltd, April 2006, price £47.99. To order your copy please go to or phone Elsevier customer services on 01865 474000.

Practical General Practice is compiled by Alex Khot, a GP in East Sussex, and Andrew Polmear, a retired GP and former senior research fellow at the University of Sussex

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