How to safely prescribe steroids in Aphthous ulcers?

Question

Topical steroids are the mainstay of treatment in Aphthous ulcers.

An important differential diagnosis of oral aphthous ulcers is intra oral herpetic ulcers. And sometimes, it may be difficult to differentiate between the two.

Applying steroids on herpetic ulcers can have serious sequelae, including severe spread of the infection.

How can a practicing physician safely prescribe topical steroids to a patient of aphthous ulcers?

Answer 1

This is an excellent question!

It is indeed important to differentiate Aphthous ulcers (Canker sores) and Herpetic ulcers, due to the difference in therapeutic approach.

The Aphthous ulcers have the following characteristics:

• Generally located on mobile muquosa (also called non-keratinised tissus), rarely on immobile muquosa and never on the lips.
• Presence of a red halo around the aphte.
• Presence of one or a few ulcers (up to 10) can be minor (3-10 mm in diameter) or major (>10 mm diameter)
• If many aphtes are present (>10), it is called an aphthous stomatitis
• Pain is felt upon contact
• Treatment: Can heal on its own, or can be treated topically with corticosteroids

The Herpetic ulcers have the following characteristics:

• Almost always located on immobile muquosa (also called keratinised tissus), namely the gingiva, the palate and often on the lips.
• Sore throat and/or fever before appearance of vesicular lesions,
• Appearance of vesicular lesions before appearance of ulcers (see image below)
• Treatment: antiviral drugs to decrease pain and and length of symptoms.

Sources (other than formal training):

• http://emedicine.medscape.com/article/218580-clinical
• https://www.nlm.nih.gov/medlineplus/ency/article/000606.htm
• http://www.skinsight.com/adult/aphthousUlcerCankerSore.htm?Imiw9cApl

N.B.: Aphthous ulcers can look in rare cases like Herpetic Ulcers. They are smaller than 3mm, often bundled in clusters, and therefore bare the name "Herpetiform Aphtae".