Aphthous ulcer

What is an aphthous ulcer?

An aphthous ulcer is an ulcer that forms on the mucous membranes. They are also called aphthae, aphthosis, aphthous stomatitis and canker sores.

An aphthous ulcer is typically a recurrent round or oval sore or ulcer inside the mouth on an area where the skin is not tightly bound to the underlying bone, such as on the inside of the lips and cheeks or underneath the tongue. Aphthous ulcers can also affect the genitalia in males and females.

Recurrent aphthous ulcers are mostly a minor nuisance, but they are associated with significant health problems in some people.

Who is at risk of aphthous ulcer?

Anyone can get an aphthous ulcer; 20% of the population have one or more, at least occasionally. They usually first appear in childhood or adolescence, and more commonly affect females than males.

Interestingly, smoking may be protective against aphthae, even though smoking makes many oral and skin conditions worse.

Non-sexually acquired genital ulceration

Non-sexually acquired genital ulceration (NSGU) refers to an aphthous ulcer in genital sites. A genital aphthous ulcer is also called a Lipschutz ulcer.

• A genital aphthous ulcer is more common in females than in males.
• It may be accompanied by considerable pain and swelling.
• Reactive genital ulcer follows an infection. 

NSGU is more likely than simple oral aphthosis to be associated with systemic illness, such as:

• Behcet syndrome
• Gluten-sensitive enteropathy (celiac disease)
• Inflammatory bowel disease
• Human immunodeficiency virus (HIV) infection.

See images of vulval ulcers... 

What causes an aphthous ulcer?

The exact reason why aphthous ulcer develops is not yet clearly defined. Approximately 40% of people who get aphthous ulcers have a family history of aphthous ulcer. Current thinking is that the immune system is disturbed by some external factor and reacts abnormally against a protein in mucosal tissue.

Factors that seem to trigger outbreaks of ulcers include:

• Emotional stress and lack of sleep
• Mechanical trauma, for example, self-inflicted bite
• Nutritional deficiency, particularly of vitamin B, iron, and folic acid
• Certain foods, including chocolate
• Certain toothpastes; this may relate to sodium laureth sulfate (the foaming component of toothpaste) 
• Menstruation
• Certain medications, including nicorandil, given for angina
• Viral infections.

What is the differential diagnosis of aphthous ulcer?

Other causes of mouth ulcer should be considered, including:

• Herpes simplex 
• Herpangina
• Erythema multiforme
• Fixed drug eruption.

What are the signs and symptoms of an aphthous ulcer?

Recurrent aphthous ulcer usually begins as a round yellowish elevated spot surrounded by a red halo. This then breaks down into a punched-out ulcer, which is covered with a loosely attached white, yellow or greyish membrane. Surrounding tissue is healthy and unaffected. The ulcer can be painful, particularly if irritated by movement or eating certain types of food such as citrus fruit.

People may experience a single ulcer or multiple ulcers. Multiple ulcers tend to be widely distributed throughout a person's mouth.

Aphthous ulceration is classified into three types.

• Recurrent minor aphthous ulcer (80%). This is less than 5 mm in diameter and heals within 1–2 weeks.
• Major aphthous ulcer, which is large (often more than 10 mm) and takes weeks or months to heal and leaves a scar.
• Herpetiform ulcers, which are multiple pinpoint ulcers that heal within a month. These are most commonly on the tongue.

Aphthous ulceration

Aphthous ulceration

Aphthous ulceration

What tests should be done in aphthous ulceration?

Most people affected by occasional minor aphthous ulceration do not require tests. They are undertaken if there are recurrent attacks of multiple or severe oral ulcers or complex aphthosis.

Blood tests may include:

• Blood count, iron, B12 and folate studies
• Gluten antibody tests for coeliac disease
• Faecal calprotectin test for Crohn disease

Swabs for microbiology evaluate the presence of Candida albicans, Herpes simplex virus and Vincent's organisms.

What is the treatment for an aphthous ulcer?

There is no cure for an aphthous ulcer. Most recurrent minor aphthous ulcers heal within 1–2 weeks without any treatment. The main goal of treatment is to lessen pain and discomfort and promote healing.

General measures

• Protective pastes that form a barrier over the ulcer so that exposure to irritating substances is reduced.
• Superficial tissue cauterization using silver nitrate stick
• Local anaesthetics benzocaine and lignocaine (lidocaine) to reduce pain
• Medicated toothpaste without sodium laureth sulfate
• Antibacterial mouthwashes to reduce secondary infection.
• Avoidance of foods that trigger or exacerbate the ulcers.
• Dietary supplements of vitamins or minerals, if the diet is deficient.
• Reduction in stress

Prescribed medicines for aphthous ulcer

Topical prescription medicines include:

• Tetracycline suspension as a mouthwash
• Topical corticosteroids as lotions, creams or paste, often triamcinolone in dental paste
• Calcineurin inhibitors: topical pimecrolimus or tacrolimus.

In severe cases, particularly if there are systemic symptoms, anti-inflammatory oral medications may be considered (off-label use):

• Tetracycline, e.g. doxycycline 50-100mg daily for 3-6 months or longer.
• Dapsone
• Colchicine
• Systemic steroids
• Immunosuppressive agents such as azathioprine, methotrexate, ciclosporin
• Apremilast, which has been approved in the USA to treat oral ulcers in Behçet disease
• Tumour necrosis factor (TNF) antagonists (adalimumab, etanercept, infliximab)
• Thalidomide.