Aphthous stomatitis in AdultSee also in: Anogenital,Oral Mucosal Lesion
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SynopsisAphthous ulcers, or aphthae (canker sores), are the most common cause of recurring ulcers of the mucous membranes. They affect approximately 25% of the general population (estimates range from 20% up to 50%). The mouth is the most common site. The precise cause of aphthous ulceration is unknown, but studies point to a defect in regulation of cellular immunity that results in increased T-cell reactivity to either mucous membrane keratinocytes or microorganisms on the mucosal surface.
There are 3 morphologic types:
- Minor aphthae (Mikulicz aphthae, representing about 80% of cases) are single or multiple lesions, 1.0 cm or less in diameter, and mildly painful; they heal within 1-2 weeks without scarring. They favor the buccal mucosa, labial mucosa, and the floor of the mouth. Onset is typically around the age of 5 years.
- Major aphthae (Sutton disease, representing approximately 10%-15% of cases) are deep ulcers that are 1-3 cm in diameter. These lesions are extremely painful, last from 2-6 weeks, and generally heal with scarring. They favor the labial mucosa, soft palate, tongue, or pharynx. Systemic symptoms, such as fever and odynophagia, may be seen. These lesions begin at the onset of puberty.
- Herpetiform aphthae (representing about 5%-10% of cases) are characterized by multiple oral ulcerations, 1-3 mm in diameter, and have a clinical course similar to minor aphthous ulcers, typically healing in 1-4 weeks without scarring. They can be seen anywhere on the oral mucosa. They have a later onset, usually in adulthood, and are primarily seen in women.
There are 2 well-recognized patterns for recurring oral ulcerations:
- Simple aphthosis is primarily marked by minor aphthae that recur intermittently with disease-free intervals of weeks to months. Patients are generally young and healthy, with lesions limited to the mouth and no underlying systemic disease. Patients frequently report a family history of oral ulceration. In addition to presumed genetic risk, epidemiologic studies (and patient reports) support an association between new lesions and oral trauma, chemical irritation, emotional stress, and smoking cessation. Pregnancy and hormonal changes in menses appear to increase risk. Some studies suggest that those who were breast-fed as infants may be at decreased risk. Most affected individuals experience less severe and fewer episodes after 50 years of age.
- Complex aphthosis is marked by the near-constant presence of 3 or more oral and/or genital aphthae. When genital ulcers are involved, complex aphthosis is sometimes called Lipschütz disease. Complex aphthosis usually occurs in the presence of an underlying disease such as human immunodeficiency virus (HIV), gluten-sensitive enteropathy, inflammatory bowel disease, or Behçet disease. By definition, Behçet disease is accompanied by other findings, including genital ulcers, uveitis, and other skin and systemic inflammatory processes. Complex aphthosis is also seen in rarer conditions such as MAGIC syndrome (mouth and genital ulcers, inflamed cartilage), PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and lymphadenopathy), and cyclical neutropenia (fever approximately every 3 weeks, oral ulcers, neutropenia).
K12.0 – Recurrent oral aphthae
426965005 – Aphthous ulcer of mouth
Differential Diagnosis & PitfallsDiseases with oral ulcerations clinically distinguishable from aphthae:
- Erosive lichen planus – White striae radiating from the periphery of the ulcer.
- Hand-foot-and-mouth disease – Usually has skin lesions.
- Herpangina – Localized to the soft palate and tonsillar region.
- Chemotherapy-induced mucositis
- Pemphigus vulgaris – Ragged ulcers and erosions that are chronic.
- Mucous membrane pemphigoid (cicatricial pemphigoid) – Gingival involvement; bullae.
- Dermatitis herpetiformis – Skin lesions predominate.
- Chronic ulcerative stomatitis – Similar to erosive lichen planus.
- Herpes zoster – Unilateral distribution; cutaneous vesicles.
- Varicella – Cutaneous lesions predominate.
- Herpes simplex virus, including primary herpes gingivostomatitis – Involvement of keratinized mucosa.
- HIV infection – Recurrent painful oral ulcers.
- Chemical burn (eg, from holding aspirin against the mucosa)
- Oral candidiasis – Typically painless or mild burning sensation; no actual ulceration.
- Squamous cell carcinoma – Chronic lesion, lasting weeks to months.
Drug Reaction DataBelow is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.
Patient Information for Aphthous stomatitis in Adult
OverviewCanker sores (aphthous ulcers), or aphthae, are the most common cause of periodic (recurring) ulcers inside the mouth and genital linings (mucous membrane surfaces). Their cause is unknown, but stress, lack of sleep, trauma, and perhaps some vitamin deficiencies, toothpastes, and foods can make the condition worse. Some people with anemia and other medical conditions that weaken the immune system may be more likely to develop canker sores.
There are 3 types of canker sore:
- Minor aphthae (80% of cases)
- Major aphthae (Sutton disease, approximately 10% of cases)
- Herpetiform aphthae (10% of cases)
Major aphthae are extremely painful, last from 2-4 weeks, and generally cause scars after they heal.
Herpetiform aphthae progress in a way that is similar to minor aphthous ulcers.
Who’s At RiskCanker sores affect approximately 25% of the general population. They are more common in women, and they usually start to appear in children or teens.
People infected with HIV/AIDS are often severely affected with canker sores.
Signs & SymptomsMinor aphthae are single or multiple lesions, 1.0 cm or less in diameter.
Major aphthae are deep ulcers greater than 2.0 cm in diameter.
Herpetiform aphthae appear as multiple ulcerations.
The most common locations of canker sores are inside the mouth or lips or on the tongue. The genitals may also be affected. The sores can have a white, gray, or yellow base.
Self-Care GuidelinesThere is no cure for canker sores. Most heal in 1-2 weeks, but the following measures may help relieve the pain:
- Apply protective pastes to form a barrier over the sore.
- Apply local anesthetics (benzocaine, lidocaine) to help numb the area.
- Use antibacterial mouthwashes.
- Avoid products or foods that seem to trigger episodes.
- Maintain a good diet or take vitamins.
- Get enough sleep and reduce stress.
When to Seek Medical CareSee your doctor if canker sores do not heal, occur frequently, or if you have extreme discomfort or pain.
TreatmentsTreatment with topical steroids or other medications applied to the affected area, to speed up healing of the lesions, can be used. These include:
- Topical calcineurin inhibitors (tacrolimus or pimecrolimus)
- Prednisone in severe cases
Bolognia, Jean L., ed. Dermatology, pp.419, 1087. New York: Mosby, 2003.
Freedberg, Irwin M., ed. Fitzpatrick's Dermatology in General Medicine. 6th ed. pp.1115-1116, 1098-1099, 2360, 2467. New York: McGraw-Hill, 2003.
Aphthous stomatitis in AdultSee also in: Anogenital,Oral Mucosal Lesion