Case #22 Discussion

Summary: The ulcers in this patient are characterized by abrupt (acute) onset, healing of ulcers in a predictable period of time, and continued formation of new ulcers. The ulcers involve multiple nonkeratinized oral mucosal sites.  No skin, eye, or genital lesions or cervical lymphadenopathy are reported.  Lesions to Exclude from the Differential Diagnosis: Epidermolysis Bullosa   ~The onset of blisters and ulcers almost always begins at birth or early childhood.   ~Lesions of the skin are present.   ~Lesions do not heal in a consistent period of time. Viral Infections             ~Do not recur and heal in a consistent amount of time, except for recurrent herpes.    ~Recurrent herpes involves keratinized mucosal surfaces. Mycotic Infections (candidosis)   ~Candidosis is not predominantly an ulcerative disease.           ~Lesions do not heal in a consistent amount of time. Autoimmune Diseases   ~Chronic and persistent with a more gradual onset   ~Lesions do not heal in a consistent amount of time. Idiopathic   ~Erythema multiforme *Lesions occur on both keratinized and nonkeratinized mucosal surfaces. *Each ulcer does not heal in a consistent amount of time. *Skin lesions (target lesions) are sometimes present but do not occur in all patients.   ~Epithelial Dysplasia, Carcinoma-in-situ, and Squamous cell carcinoma *Clinical appearance is erythroplakia and/or leukoplakia with minimal formation of ulcers *Lesions are persistent, and each lesion does not heal completely.   ~Lichen Planus, Medication-induced mucositis, and Contact stomatitis *Lesions are persistent and chronic.  *Lesions do not recur and then heal in a consistent amount of time Lesions to Include in the Differential Diagnosis: Aphthous Ulcers   ~Ulcers have an abrupt or acute onset, and each ulcer heals in a predictable amount of time.   ~Ulcers occur on non-keratinized mucosal surfaces.   ~Skin lesions and cervical lymphadenopathy are not present. Management: Explain to the patient the nature of the disease, that there is no cure, and that the goal of treatment is to control the ulcers. Most commonly treated initially with topical corticosteriods (example: triamcinolone acetonide, 0.1% or 0.2% mouthrinse). For patients with constantly forming new lesions (as in this case), a short burst of systemic corticosteroids may be necessary but must be followed by topical steroids.  Final Diagnosis: Aphthous Ulcers