Traumatic and 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
• Where ulceration is recurrent, check HIV status and endomysial antibodies.
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.
• 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 www.elsevierhealth.com 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