APHTHOUS STOMATITIS ======================== There are so many recipes out there for "magic mouthwash" would anyone like to share those which have been particularly helpful? Brooke jackson, MD ------------------ Funny you should ask that particular question, as I was just considering trying to publish (maybe on the Internet) some anecdotal success with my own formulation. I have treated 3 patients, 2 male and 1 female, with apthous stomatitis with triamcinolone mouthwash. The concentration for compounding is 0.1% traimcinolone acetonide from injection. I initially used Scope Mouthwash as the vehicle and , although it was well accepted from a taste standpoint, it was cosmetically unacceptable because of precipitation of the injection vehicle which I assume was due to the high water content of the Scope. The last 2 times I have used Benadryl elixir as the mouthwash vehicle with very good results. All 3 patients had prompt relief and resolution of their lesions in less than 7 days with all having some improvement within 3 days. Because I was unable to obtain systemic absorption data with this particular route of administration for a corticosteroid, I opted to play it safe and prescribe a declining frequency regimen...in other words, swish, hold for a few minutes and spit 4 times a day for 3 days, twice a day for 3 days, then once a day for 3 days then stop. None of the patients have described any complaints or side effects of either the compound or regimen, including the 27 year old female who has been using it about once a month for the last 11 months. All 3 patients had other causes for mouth ulcers eliminated on the basis of history and physical exam (none were biopsied and all looked typical for apthous stomatitis). The only drawback is the cost of the product. The local pharmacy which has compounded all three times for me(who now call it Z-wash) charges about $35.00 for 400ml. It is easy to compound, with 1mg triamcinolone per ml Benadryl, a 10ml vial of triamcinolone 40mg/cc will quickly make up 400ml of solution with no waste or broken packages for the pharmacy and a minimum of compound time for the patient. While I admit that 3 patients is hardly a study population woth noting, these 3 patients had no relief with other regimens including Kenalog in Orabase, colchicine, and tetracycline:nystatin mouthwash and they are very pleased with the outcome. I would be interested in the results of quantification of any systemic absorption. If(or, optimistically, when) I am granted a Dermatology residency, perhaps that would be a good research topic. I have tentatively scheduled some baseline adrenal studies on one patient for the coming months. E. Zabawski, Jr., DO, R.Ph. -------------------------- I've had great success with Temovate or Ultravate ointment [sometimes with 2% Nizoral w/w tabs crushed and added to prevent thrush]. IMPORTANT: apply to a bit of gauze or paper towel then apply THAT to the oral lesion for 10 minutes, then spit it out. Great way to nip early lesions in the bud. Also good for oral LP, oral DLE, and LS et A of the perineum. Kevin C. Smith, MD, FRCPC ------------------------- For the past 25 years i have used the following mixture that controls the frequency of recurrences. elixir of benadryl 30cc elixir of decadron 30cc tetracycline syrup 125 or 250mg/5cc 30cc mix sig: apply with a q-tip bid to affected ulcer areas note: a swish method can be used but the patient uses more of the mixture also, if tetracycline syrup is not available then you can substitute erythromycin syrup 250mg/5cc. lastly, for large tender ulcers add tetracycline 250 or 500 mg QID x 10days. Thomas F. Downham II, MD ------------------------ Healthy 20 year old woman with recurrant mouth ulcers every two weeks, cover 50% or so of the mucosal surfaces excluding gums, including inner lips. Totally disabling. Biopsy / just apthous ulcers, no LE, no vasculitis, no Behcets, no Herpes, no blistering disease. Abnormal Labs: ANA 1:320 homogenous, Sm negative, RNP pos 1:800. She is not anemic, folate, B12, iron are normal. No sx of MCTD. Diane Thaler ------------ She could have "oral lupus", and I'd certainly check for inflammatory bowel disease of all types! After Steroids settle her, I'd strongly consider Dapsone or colchicine. Robert I. Rudolph, M.D. ----------------------- How long has she been plagued with the aphthae? Did this woman ever smoke? If she did, did she stop recently? If she did stop smoking, have her resume it and see what happens. There are many medications that have been reported to provoke canker sores. Among them are aspirin, NSAIDS, and many sulfa drugs. I have found that oral tetracycline "gargles," (not the tetracycline suspension, but the capsules [250 mg], shaken up in a suspension in 2 ounces of water and then applied), often helps. Every 3 or 4 hours. Jerry Litt ---------- Cephalexin suspension (Keflex or Ceporex ds) tastes better. One teaspoon QID gargled for one to three minutes then swallowed. Wears any braces or ill fitting dentures? Jonathan Yu, MD ---------------- Test for HIV and for hepatitis. Barbara R. Reed, MD -------------------- Re: Aphthous Stomatitis IF that is the diagnosis, I consider it a form of oral pathergy. Consider Crohn's disease, Behcet's disease (early), and other neutrophilic diseases such as pyoderma gangrenosum. Take patient off all foods with sharp borders, such as chips, nuts, etc. Off all excessively hot foods such as pizza (nobody waits for pizza to cool- the delivery boy is too slow). Etc. Intralesional TAC 5-10mg/cc EARLY may abort a lesion. Consider oral lichen planus as well: ulcerative form AND recurrent intraoral herpes simplex. A 3-4 month course of suppressive valacyclovir may be helpful, diagnostically, as we all assume the serological studies aren't regarding herpes simplex, recurrent type. Patrick Carrington ------------------ I have not seen a case of MCTD with mucosal ulcers in the past 15+ years. Usually the ANA is speckled and of high titre along with the +RNP. The patient may have to be followed to see if this emerges. It will be interesting to hear what Rheumatology thinks. Goog luck!. Tom Downham ----------- Besides oral LE consider cyclic neutropenia. Follow serial CBC's for a month or two to see if the WBC's dip when the lesions flare. Gene Sienkiewicz, M. D ---------------------- Does she have a family history of aphthous ulcers? Any relation to diet, especially to milk? Her serology ANA and RNP titres are rather high to be a false negative. Looks like an auto immune aphthous stomatitis - may eventually turn out to be a MCTD. Henry Foong MRCP ---------------- It will be interesting to see if she responds to the hydroxychloroquine. Also, based on the steroid resistance discussion: her mother related that she herself once got a steroid injection for hives which did not work-but then a p.o. steroid did! We shall see if her child, my patient, responds to prednisone, or if I chose the incorrect steroid. Diane Thaler ------------ My differential would be major aphthosis(early Behcet's) vs. odd EM vs. Cic. pemph or Lin. IgA, vs chronic ulcerative stomatitis (CUS) (ala Ernie Beutner). DIF might help a lot and may even need to be repeated. If its CUS then plaquenil is often magic. Cyclic neutropenia may also do this. Guy Webster ----------- As recommended by one of our esteemed colleagues, my young woman patient with the positive ANA and terrible recurrant diffuse mouth ulcers is doing very well on 400 hydroxychloroquine after 3 weeks. She is still getting some ulcers, but they are fewer in number and no longer are uncomfortable. She can fully function and eat whenever. Thanks for the suggestion of CUS as the diagnosis and hydroxychloroquine as the treatment. Diane Thaler ------------