In severe cases with a high recurrence rate and in HIV-infected patients, thalidomide 100-300 mg/day for 2-3 months may result in complete remission of the ulcers for a long time. However, teratogenesis and polyneuropathy preclude the routine use of thalidomide.
Clinicians should be aware that safe prophylaxis for prevention of recurrences of RAU in the long term is not possible.
Alternative Therapies
In severe cases many other systemic medications have been used with ambiguous results. These include dapsone, levamisole hydrochloride, colchicine, azathioprine, interferon alpha, cyclosporine, pentoxifylline, and recently rebamipide, a gastroprotective drug.
References
Ball SC, Sepkowitz KA, Jacobs JL. Thalidomide for treatment of oral aphthous ulcers in patients with human immunodeficiency virus: Case report and review. Am J Gastroenterol 1997;92:169–170.
Brown RS, Bottomley WK. Combination immunosuppressant and topical steroid therapy for treatment of recurrent major aphthae. Oral Surg Oral Med Oral Pathol 1990,69:42–44.
Fontes V, Machet L, Huttenberger B, et al. Recurrent aphthous stomatitis: Treatment with colchicine. An open trial of 54 cases. Ann Dermatol Venereol 2002;129:1365–1369.
Haeyrinen-lmmonen R, Sorsa T, Pettilae J, et al. Effect of tetracyclines on collagenase activity in patients with recurrent aphthous ulcers. J Oral Pathol Med 1994;23:269–272.
Laskaris G. Color Atlas of Oral Diseases, 3rd edition. Thieme: Stuttgart, 2003.
Laskaris G. Aphthous stomatitis. In: Katsambas A, Lotti TM (eds), European Handbook of Dermatological Treatments. Springer: Berlin, 2003.
MacPhail L. Topical and systemic therapy for recurrent aphthous stomatitis. Semin Cutan Med Surg 1997;16:301.
Matsuda T, Ohno S, Hirohata S, et al. Efficacy of rebamipide as adjunctive therapy in the treatment of recurrent oral aphthous ulcers in patients with Behçet’s disease: A randomised, double-blind placebo-controlled study. Drugs R D 2003;4:19–28.
Paterson DL, Georghiou PR, Allworth AM, Kemp RJ. Thalidomide as treatment of refractory aphthous ulceration related to human immunodeficiency virus infection. Clin Infect Dis 1995;20:250–254.
Rees TD, Binnie WH. Recurrent aphthous stomatitis. Dermatol Clin 1996;14:243–256.
Scully C, Porter SR. Recurrent aphthous stomatitis: Current concepts of etiology, pathogenesis and management. J Oral Pathol Med 1989, 18:21–27.
Vincent SD, Lilly GE, Clinical, historic, and therapeutic features of aphthous stomatitis. Oral Surg Oral Med Oral Pathol 1992;74:79–86.
Woo SB, Sonis ST. Recurrent aphthous ulcers: A review of diagnosis and treatment. JADA 1996;127:1202–1213.
Ariboflavinosis
Ariboflavinosis or vitamin B2 deficiency is an unusual disorder that usually occurs in combination with other vitamin deficiencies.
Deficiency of vitamin B2 occurs due to dietary inadequacy, achlorhydria, malabsorption, alcoholic cirrhosis, hypothyroidism, and drugs.
Oral Manifestations
•Angular cheilitis
•Atrophy of the filiform papillae resulting in a smooth red tongue
•Dry and cracked lips
Other Manifestations
•Skin lesions include perioral seborrheic dermatitis, scaly papules, fissures, and, rarely, ulcers
•Conjunctivitis and photophobia
•Anemia, mental disorders, and slowing of higher functions: weakness may occur
The diagnosis is based mainly on the medical history and clinical features. Biochemical analysis of vitamin B2 status and measurement of erythrocyte glutathione reductase helps confirm the diagnosis.
•Pellagra
•Plummer-Vinson syndrome
•Other vitamin B complex deficiencies
•Zinc deficiency
•Angular cheilitis
Basic Guidelines
•Improve or treat any underlying illness.
•Eat foods rich in vitamin B2 (meat, fish).
Suggested Therapies
•Treatment consists of riboflavin 5-15 mg/day taken orally until the clinical signs and symptoms are resolved. In severe cases 2-4 mg two times daily can be given parenterally.
•Topical antifungals such as nystatin or miconazole ointment may be used for the treatment of angular cheilitis.
•A high level of oral hygiene is necessary.
Barthelemy H, Chouvet B, Cambazard F. Skin and mucosal manifestations in vitamin deficiency. J Am Acad Dermatol 1986;15:1263.
Mataix J, Aranda P, Sanchez C, et al. Assessment of thiamin (vitamin B2) status in an adult Mediterranean population. Br J Nutr 2003;90:661–666.
Miller SJ. Nutritional deficiency and the skin. J Am Acad Dermatol 1989;21:1–30.
Roe DA. Riboflavin deficiency: Mucocutaneous signs of acute and chronic deficiency. Semin Dermatol 1991;10:293–7.
Aspergillosis
Aspergillosis is an opportunistic fungal infection with a broad spectrum of clinical manifestations.
Aspergillus fumigatus and A. flavus are the main pathogenic Aspergillus species. Immunocompromised patients such as those with HIV infection, neutropenia, leukemia, and diabetes, those receiving immunosuppressant agents and organ transplantation, and patients with chronic respiratory diseases are more susceptible to Aspergillus infection.
There are several types of Aspergillus infection: a) allergic aspergillosis, b) aspergilloma (fungus balls), c) invasive aspergillosis (pulmonary involvement in 90-95% and extrapulmonary involvement in 20-25%), d) chronic necrotizing pulmonary aspergillosis, and e) superficial aspergillosis with skin, ear, and eye involvement.