eMedicine Specialties > Dermatology > Diseases of the Oral Mucosa
Eosinophilic Ulcer: Treatment & Medication
Updated: Oct 2, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
- Dental-related trauma
- The source of chronic irritation must be eliminated when an eosinophilic ulcer is due to obvious trauma.
- Referral to a dentist is recommended if the lesion is related to a tooth, dental restoration, or appliance.
- Although extraction of the anterior primary teeth is not recommended, this may resolve the ulcerations in Riga-Fede disease. However, if the teeth are stable, they should be retained. In these cases, breastfeeding should be discontinued, or a protective shield should be constructed to prevent any further trauma. These measures are usually sufficient to resolve the condition.
- Treatment modalities
- Palliative care: Nonsteroidal anti-inflammatory drugs (NSAIDs) or topical anesthetics (eg, viscous lidocaine, benzocaine, dyclonine) may be used to provide temporary relief and comfort when the patient eats. A magic mouthwash may also provide symptomatic relief.
- Therapeutic care: Some clinicians suggest that the use of corticosteroids may delay healing; however, a mixture of Orabase and a topical corticosteroid ointment (eg, clobetasol, fluocinonide, triamcinolone) is often effective. Dexamethasone elixir is also effective. Although unnecessary, systemic or intralesional corticosteroids may be used.
Surgical Care
- As a rule, if the lesion does not resolve or it continues to appear ominous after 2 weeks of treatment, biopsy is warranted.
- After biopsy, rapid healing of the ulcer is often typical, even with large eosinophilic ulcers, and no further treatment is necessary.
- Occasionally, lesions may have to be surgically excised.
Consultations
- Consultation with a dentist may be indicated to evaluate and repair fractured teeth or restorations or to alter dentures.
- Consultation with an internist may be indicated for the evaluation of an underlying systemic condition in cases in which the ulcer persists, even after biopsy.
Diet
Advise patients to maintain hydration and nourishment.
- A soft diet is recommended for patients with painful ulcers and to avoid any further irritation.
- Nutritional supplements, such as Ensure or Boost, may be necessary.
- Advise patients to avoid eating acidic or spicy foods because they may cause additional discomfort.
Medication
NSAIDs or topical anesthetics (eg, viscous lidocaine, benzocaine, dyclonine) may be used to provide temporary pain relief and comfort while the patient eats.
Some clinicians suggest that the use of corticosteroids may delay healing; however, a mixture Orabase with a topical corticosteroid ointment (eg, clobetasol, fluocinonide, triamcinolone) often is effective.
Although unnecessary, treatment with systemic prednisone or intralesional injections of triamcinolone has been successful in some patients.
Dexamethasone elixir and magic mouthwash may also provide relief.
Topical anesthetics
These agents may provide temporary symptomatic relief of pain. They also may improve the patient's comfort while eating.
Viscous lidocaine 2% (Xylocaine)
Anesthetic liquid prescribed to treat painful lesions of the oral mucosa or lips. Inhibits neuronal membrane depolarization, blocking nerve impulses.
For small lesions, apply to ulcer with a cotton-tipped applicator. Generally not recommended for use in children because therapeutic doses usually approach potentially toxic levels. If necessary, use lowest effective dose and supervise children.
Adult
15 mL (1 tbsp) topically or swish and spit q3h prn; not to exceed 8 doses/24h, 4.5 mg/kg, or 300 mg/d
Pediatric
<3 years: Not established
>3 years: Apply 3.75-5 mL topically or swish and spit q3h
If significant systemic levels are reached (only theoretically with local or topical administration), systemic drug interactions may occur with medications metabolized by or affecting metabolism by CYP (P-450) 3A4 (eg, digitalis, disopyramide, ephedrine, isosorbide dinitrate, mexiletine, pentobarbital, phenytoin, propafenone, propanone, tocainide)
Documented hypersensitivity; avoid IV use in Adams-Stokes syndrome and Wolff-Parkinson-White syndrome
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
For external or mucous membrane use only; not for use in eyes; advise patients not to swallow because serious adverse effects can occur if too much is ingested
Benzocaine (Americaine, Benzocol, Cylex)
Inhibits neuronal membrane depolarization, blocking nerve impulses. In pediatric patients, this is a safe alternative to lidocaine.
Adult
Apply 2-3 gtt topically or swish and spit q4-6h prn; not to exceed 5 g/d
Pediatric
Administer as in adults
None reported
Documented hypersensitivity to ester-type anesthetics and PABA
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Potent sensitizer and more likely to induce allergy if applied to broken or fissured/dermatitic skin; methemoglobinemia may occur; not intended for use when infection is present
Dyclonine (Dyclone)
Ketone local anesthetic agent administered topically. Affects cell membrane permeability and blocks impulses at peripheral nerve endings in mucosa.
Adult
Mouth sores: Apply 5-10 mL of 0.5-1% topically to oral mucosa q2-3h prn or swish and spit tid/qid prn; not to exceed 200 mg, 40 mL of 0.5% solution, or 20 mL of 1% solution
Pediatric
Administer as in adults
Coadministration with St. John's wort may cause an increased risk of cardiovascular collapse and/or delayed emergence from anesthesia
Documented hypersensitivity; not for use around conjunctiva
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May increase risk of aspiration (impairs swallowing); caution in shock or heart block; caution in presence of severely traumatized mucosa because rapid absorption possible
Analgesics
Analgesics are used for the relief of mild to moderate pain.
Ibuprofen (Motrin, Advil, Pediaprofen)
DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d
Pediatric
<6 months: Not established
6 months to 12 years: 4-10 mg/kg/dose PO tid/qid
>12 years: Administer as in adults
Coadministration with aspirin increases risk of serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may increase risk of prerenal azotemia in patients taking an ACE inhibitor; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding), increases risk of hemorrhage if used with other anticoagulants, thrombolytic agents, or alcohol; may increase risk of methotrexate toxicity; phenytoin and lithium levels may be increased when administered concurrently
Documented hypersensitivity (including aspirin); peptic ulcer disease; recent GI tract bleeding or perforation; renal insufficiency; high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Category D in third trimester of pregnancy; not recommended if patient is breastfeeding; caution in congestive heart failure, hypertension, and decreased renal or hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy; Pediaprofen susp and Motrin susp contain sucrose (caution in DM); Motrin chewable tab contains aspartame (caution if PKU)
Acetaminophen (Tylenol, Tempra, FeverAll, Aspirin-Free Anacin)
DOC for pain relief in patients with documented hypersensitivity to aspirin or NSAIDs, those with upper GI tract disease, or those who are taking oral anticoagulants.
Adult
325-650 mg PO q4-6h prn or 1000 mg tid/qid; not to exceed 4 g/d
Pediatric
<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses/24 h
Rifampin can reduce analgesic effects; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity; may potentiate oral anticoagulants (eg, warfarin); monitor chloramphenicol concentrations and adjust dosage of chloramphenicol as necessary; concomitant diflunisal results in a 50% increase in plasma concentrations of acetaminophen; coadministration with zidovudine may result in neutropenia or hepatotoxicity
Documented hypersensitivity (including sulfites); known G-6-PD deficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity possible in long-term alcoholism with various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; many OTC products contain acetaminophen (combined use with these products may result in cumulative doses exceeding recommended maximum dose); caution with formulations that contain aspartame in patients with PKU; caution in patients with history of anemia, cardiac, pulmonary, renal, or hepatic disease; patients that have taken therapeutic doses of acetaminophen may have falsely elevated serum uric acid levels using the chemical phosphotungstic acid method
Dental aids and preparations
These are topical corticosteroids that share anti-inflammatory, antipruritic, and vasoconstrictive properties. However, they should be mixed with a carrier such as Orabase to ensure adherence of the drug to the mucosal surface. Otherwise, saliva quickly washes away the medication.
Clobetasol 0.05% dental paste (Temovate in Orabase)
Class I superpotent topical steroid; suppresses mitosis and increases synthesis of proteins that decrease inflammation and cause vasoconstriction. Ointment is recommended for intraoral use. Most pharmacists mix 15 g of clobetasol with 15 g of Orabase; this should be indicated on the prescription.
Adult
Apply thin film tid for as long as 2 wk; do not rub in
Pediatric
<12 years: Not recommended
>12 years: Administer as in adults
None reported
Documented hypersensitivity; herpes simplex infection; fungal, viral, or tubercular mucosal lesions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Prolonged therapy may suppress adrenal function; with prolonged use of intraoral corticosteroids, superimposed candidal infection may develop; in predisposed patients (eg, those with HIV/AIDS or diabetes), a topical antifungal medication (eg, clotrimazole, nystatin) should also be prescribed
Fluocinonide 0.05% dental paste (Lidex in Orabase)
Class II high-potency topical corticosteroid that inhibits cell proliferation; immunosuppressive and anti-inflammatory. Ointment is recommended for intraoral use. Most pharmacists mix 15 g of fluocinonide with 15 g of Orabase; this should be indicated on the prescription.
Adult
Apply thin film tid for as long as 2 wk; do not rub in
Pediatric
<12 years: Not recommended
>12 years: Administer as in adults
None reported
Documented hypersensitivity; herpes simplex infection; fungal, viral, or tubercular mucosal lesions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May cause adverse systemic effects if used over large areas, denuded areas, on occlusive dressings, or for prolonged periods; with prolonged use of intraoral corticosteroids, superimposed candidal infection may develop; in predisposed patients (eg, those with HIV/AIDS or diabetes), a topical antifungal medication (eg, clotrimazole, nystatin) should also be prescribed
Triamcinolone acetonide 0.1% dental paste (Kenalog in Orabase)
Group III, intermediate potency. Used to treat inflammatory mucosal lesions that are responsive to steroids. Decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability. Ointment is recommended for intraoral use. Most pharmacists mix 15 g of triamcinolone with 15 g of Orabase; this should be indicated on the prescription.
Adult
Apply thin film tid/qid until favorable response obtained
Pediatric
<12 years: Not recommended
>12 years: Administer as in adults
None reported
Documented hypersensitivity; fungal, viral, and mycobacterial mucosal infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Not for use in decreased skin circulation; prolonged use, application over large areas, and use of potent steroids and occlusive dressings may result in systemic absorption; systemic absorption can cause Cushing syndrome, reversible HPA-axis suppression, hyperglycemia, or glycosuria
Corticosteroids
These agents have anti-inflammatory properties and cause profound and varied metabolic effects. They modify the body's immune response to diverse stimuli.
Dexamethasone (Decadron, Dexone, Hexadrol, Methasone)
Elixir for various allergic and inflammatory diseases. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability. Supervise pediatric patients during administration.
Adult
Saturate 2 X 2 gauze with medication and hold in mouth over affected area as long as possible and spit out qid
Pediatric
Administer as in adults
Coadministration with estrogens may decrease clearance; when used with digoxin, digitalis toxicity secondary to hypokalemia may increase; phenobarbital, phenytoin, and rifampin may increase the metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics; coadministration with ritonavir may significantly increase serum concentrations of prednisone; concomitant therapy with montelukast may result in severe peripheral edema; clarithromycin may increase risk of psychotic symptoms
Postmarketing surveillance reports indicate that risk of tendon rupture may be increased in patients receiving concomitant fluoroquinolones and corticosteroids, especially elderly patients; administration of asparaginase concurrently with or before prednisone therapy may result in increased toxicity
Documented hypersensitivity; active bacterial or fungal infection
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Use only externally (ingestion of excess medication may increase risk of multiple complications, including severe infections)
Prednisone (Orasone, Deltasone, Meticorten)
May decrease inflammation by reversing increased capillary permeability and suppressing PMN activity. In most cases, systemic corticosteroids are unnecessary in the management of eosinophilic ulcers. Dividing dose may increase efficacy, but also increase risk of adrenal suppression/adverse effects.
Adult
10-40 mg/d PO qd or divided bid/qid; taper over 2 wk as symptoms resolve
Pediatric
2 mg/kg/d PO qd or divided bid/qid; taper over 2 wk as symptoms resolve
Coadministration with estrogens may decrease clearance; when used with digoxin, digitalis toxicity secondary to hypokalemia may increase; phenobarbital, phenytoin, and rifampin may increase the metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics; coadministration with ritonavir may significantly increase serum concentrations of prednisone; concomitant therapy with montelukast may result in severe peripheral edema; clarithromycin may increase risk of psychotic symptoms
Postmarketing surveillance reports indicate that risk of tendon rupture may be increased in patients receiving concomitant fluoroquinolones and corticosteroids, especially elderly patients; administration of asparaginase concurrently with or before prednisone therapy may result in increased toxicity
Documented hypersensitivity; connective tissue and viral infections; peptic ulcer disease; hepatic dysfunction; fungal or tubercular mucosal infections; GI tract disease
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use; a superimposed candidal infection may develop with prolonged use of corticosteroids; in predisposed patients (eg, those with HIV/AIDS or diabetes), a topical antifungal medication (eg, clotrimazole, nystatin) should also be prescribed
Palliative agents
These agents provide temporary symptomatic relief and may improve the patient's comfort while eating.
Diphenhydramine, aluminum hydroxide, magnesium carbonate (Magic Mouthwash)
Provides symptomatic relief of stomatitis. Variations of this formulation may be available through a pharmacy or may be personally specified.
Standard recipe may include 30 mL diphenhydramine (Benadryl) elixir, 60 mL calcium carbonate and magnesium hydroxide (Mylanta), and 4 g sucralfate (Carafate). Preparations may also include tetracycline (avoid tetracycline if <9 y), attapulgite (Kaopectate), lidocaine, cherry syrup (for children), or hydrocortisone.
Adult
5 mL swish and spit or swish and swallow tid ac and prn
Pediatric
Apply small amounts to lesion ac and prn
Diphenhydramine potentiates effect of CNS depressants; aluminum and magnesium reduce efficacy of fluoroquinolones, corticosteroids, benzodiazepines, and phenothiazines
Aluminum and magnesium potentiate effects of valproic acid, sulfonylureas, quinidine, and levodopa
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Diphenhydramine may exacerbate angle-closure glaucoma, hyperthyroidism, peptic ulcer, and urinary tract obstruction; xerostomia may occur
With magnesium hydroxide, caution in severe renal impairment; use aluminum-containing antacids with caution in patients with recent massive upper GI hemorrhage
More on Eosinophilic Ulcer |
| Overview: Eosinophilic Ulcer |
| Differential Diagnoses & Workup: Eosinophilic Ulcer |
 Treatment & Medication: Eosinophilic Ulcer |
| Follow-up: Eosinophilic Ulcer |
| Multimedia: Eosinophilic Ulcer |
| References |
| « Previous Page | Next Page » |
References
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Further Reading
Keywords
eosinophilic ulcer, oral eosinophilic ulcer, oral ulcer, oral mucosa ulcer, traumatic ulcerative granuloma with stromal eosinophilia, TUGSE, traumatic granuloma, Riga-Fede disease in infants, ulcerated granuloma eosinophilicum diutinum, eosinophilic granuloma of soft tissue, EU, oral ulcer
