11 - Recurrent aphthous ulcers

Question 1

What are aphthous ulcers?

Answer 1

• immunologically generated recurring ulcers
• follow a pattern depending on type
• genetically driven but can have environmental triggers

Question 2

What are the different types of RAS?

Answer 2

• minor
• major
• herpetiform
• Behcets syndrome

Question 3

Describe minor aphthous ulcers.

Answer 3

• less than 1cm
• last up to 2 weeks
• affect only non-keratinised mucosa (commonly buccal)
• heal without scarring
• respond well to topical steroids

Question 4

Why is it important to know the ulcer free period?

Answer 4

• indication of morbidity
• indicates treatment need

Question 5

Describe major aphthous ulcers.

Answer 5

• can last for months
• larger than 1cm
• can affect any part of the mucosa
• can scar (can cause stricture at throat)
• do not respond well to topical steroids (intralesional steroids successful)

Question 6

Describe herpetiform aphthae.

Answer 6

• multiple small ulcers on non-keratinised mucosa
• heal within 2 weeks
• can join together into larger areas of ulceration
• UNRELATED to herpes virus - patient is not systemically unwell

Question 7

What is Behçet’s disease?

Answer 7

• oral and genital ulceration caused by vasculitis
• HLA genetic involvement (more common in Asiatic ethnicity)
• more than 3 episodes of mouth ulcers per year
• presents with genital sores, eye inflammation, skin ulcers

Question 8

How do you treat Behçet’s disease?

Answer 8

• treat local oral disease as RAS
• systemic immunomodulation if multisystem involvement (colchicine, azathioprine, mycophenolate)
• manage with help of rheumatology

Question 9

What are the predisposing for RAS?

7

Answer 9

• genetic
• systemic diseases
• stress
• mechanical injuries
• hormonal fluctuations
• deficiencies
• viral or bacterial infections

Question 10

What is the immunopathology of RAS?

Answer 10

• cells at the basement membrane are damaged
• as the above cells shed, the lining thins and ulcer forms
• when cells return to normal, the area of ulceration heals

Question 11

How are aphthous ulcers treated?

Answer 11

• treatment at time of ulceration is ineffective
• damage has occurred prior to ulcer presentation
• treatment is most effective during prodromal period (topical or intralesional steroids)

Question 12

How does the patient identify the prodromal period of RAS?

Answer 12

Tingling in area that will ulcerate

Question 13

What investigations should be carried out when RAS present?

Answer 13

• haematinics
• coeliac screen
• allergy testing

Question 14

Describe aphthous ulceration in children.

Answer 14

• occur during periods of rapid growth
• commonly 8-11 years and 13-16 years
• usually responds to 3 months of iron supplements
• ulceration that present not within growth windows is typically genetic linked

Question 15

When should you refer to a specialist regarding RAS?

Answer 15

• if simple investigations and first line treatment is carried out and is unsuccessful
• if a child is under 12