An association between recurrent oro-genital ulceration and non-steroidal anti-inflammatory drugs

[Recurrent aphthous stomatitis]

Recurrent aphthous stomatitis (RAS) is the most common clinical disease of the oral mucosa. Its prevalence in the general population varies between 5 and 25%, with its peak appearance in the second decade of life. So far, the etiopathogenesis is not clear. In genetically predisposed patients, the effect of certain triggering factors would initiate the proinflammatory cytokine cascade directed against certain regions of the oral mucosa. Ulcers are round or oval with well-defined erythematous margins and a shallow ulcerated center covered with a gray or yellowish fibrinous pseudomembrane. The ulcers may reappear at intervals of a few days and months. Given the appearance of periodic thrush in the oral mucosa, the first thing to do is to make a correct differential diagnosis, rule out associated systemic diseases and assess treatable causes before reaching the diagnosis of RAS. At present, there is no curative treatment.

Pharmacological Management of Common Soft Tissue Lesions of the Oral Cavity

Soft tissue lesions commonly seen in the oral cavity tend to overlap in their onset, presentation, and location making it difficult to appreciate their etiology. In some instances, common oral soft tissue lesions can create confusion due to similar clinical appearance or unusual presentation; therefore, proper diagnosis of the lesion is key in pharmacologic management. In ulcerative conditions, topical steroids can decrease the symptoms and improve healing time, but do not affect the recurrence rate. Always be suspicious of soft tissue lesions that are nonresolving or recurrent lesions as they may warrant further investigation to rule out malignancy or associated systemic conditions. This article discusses key clinical presentations and the proper topical and systemic pharmacologic treatments.

Reactive non-sexually related acute genital ulcers associated with COVID-19

Acute genital ulcers (AGU), known as Lipschütz ulcers, are painful vulvar ulcers typically affecting non-sexually active girls and women. AGU have been associated with viral infections, namely, Epstein-Barr virus (EBV). Here, we describe a case of AGU in the setting of SARS-CoV-2 in a non-sexually active adolescent girl hospitalised for pain control and urinary retention, who failed a course of oral corticosteroids and then improved with colchicine. Testing for herpes simplex virus, EBV and Behcet's syndrome were all negative. Testing for SARS-CoV-2 was positive. COVID-19 increases cytokines such as tumour necrosis factor alpha, which has been shown to affect endothelial cell adhesion and neutrophil chemotaxis, leading to aphthosis.

Oral Medicine Considerations for Older Patients

With the projected increase to 1.3 billion people aged 65 years or older by 2040, healthcare professionals are faced with significant challenges in managing this population of patients. In the oral cavity, oral mucosal disease is a significant problem found in older populations. Several facial pain conditions are more likely to be seen in this cohort of patients. Although management of this group of patients may not always be appropriate in general practice, an awareness of the range of oral medicine conditions that may be encountered in older patients is essential to allow prompt referral and treatment.

Azithromycin-induced Aphthous Stomatitis: A Case Series

BACKGROUND

Azithromycin is one of the most popular antibiotics in current clinical practice. This medication generally considered to be safe and well-tolerated in different demographic populations. Like any other drug, azithromycin use is not without risk and adverse effects. In recent years, cardiovascular accidents have been announced as its major and most important side effect. But azithromycin use can be accompanied with less recognized complications which are significantly discomforting. In this article, we presented a neglected adverse effect of azithromycin in medical literature which is aphthous stomatitis.

METHODS

We detected three cases with this complication in our center during a one-year period. All the accessible clinical data were recorded and PubMed database was explored to assess the relevant literature.

RESULTS

The patients had aphthous stomatitis within 24 hours of the first dose which was healed in about 2 to 3 weeks. Naranjo scoring system showed a probable stage for this adverse drug reaction. There was no such a report in our database search process.

CONCLUSION

It could be stated that aphthous stomatitis is an important adverse effect of azithromycin that can affect the patient's quality of life during therapy and in the majority of cases, it can be neglected by healthcare practitioners.

Adverse Drug Reactions in the Orofacial Region

A wide spectrum of drugs can sometimes give rise to numerous adverse orofacial manifestations, particularly dry mouth, taste disturbances, oral mucosal ulceration, and/or gingival swelling. There are few relevant randomized double-blind controlled studies in this field, and therefore this paper reviews the data from case reports, small series, and non-peer-reviewed reports of adverse drug reactions affecting the orofacial region (available from a MEDLINE search to April, 2003). The more common and significant adverse orofacial consequences of drug therapy are discussed.

Orofacial manifestations in patients with inflammatory rheumatic diseases

The main orofacial manifestation of the inflammatory rheumatic diseases is that of Sjögren's syndrome. In addition, there is a constellation of orofacial manifestations of the inflammatory rheumatic diseases, many of which are extra-articular with some constituting presenting signs of the underlying rheumatic disease. This review will discuss the orofacial manifestations in a variety of connective tissue diseases and will also allude to the oral adverse drug reactions that may occur as a consequence of therapy.

The Pharmacologic Management of Common Lesions of the Oral Cavity

The oral ulcerations caused by aphtous lesions, herpetic lesions, candidiasis, ulcerative lichen planus, mucous membrane pemphigoid, and pemphigus vulgaris are managed in a step-up approach that can involve topical, intarlesional, and systemic pharmacologic management. This article reviews the common treatment agents, modalities, and dosages. The emphasis is on local pharmacologic therapies, yet systemic conditions that often present with such oral lesions are briefly reviewed, along with the appropriate management.

Quality of life in patients with recurrent aphthous stomatitis treated with a mucoadhesive patch containing citrus essential oil

PURPOSE

To assess 1) patient satisfaction of a mucoadhesive biopatch with citrus essential oil and 2) the change in pain severity and the oral health-related quality of life in patients with recurrent aphthous stomatitis.

PATIENTS AND METHODS

Thirty-seven patients with recurrent aphthous stomatitis participated in the study. Baseline records of personal data, ulcer assessment, visual analog scale, and Oral Health Impact Profile-14 were documented. A mucoadhesive patch was applied over the ulcer. Patients were recommended more applications if pain continued. On the fifth day, a post-therapy assessment was made.

RESULTS

The mean visual analog scale scores at baseline and posttreatment were significantly different (7.3±2.11 and 4.9±2.6, respectively; P=0.001). The mean duration of pain reduced after patch application. The mean total Oral Health Impact Profile-14 scores before and after treatment showed a statistically significant difference (P=0.001). In total, 78.4% of patients reported a considerable improvement in oral functions after treatment (P=0.008).

CONCLUSION

The mucoadhesive biopatch containing citrus essential oil resulted in satisfying pain alleviation and restoration of oral functions with a significant improvement in the oral health-related quality of life.

Adverse drug events in the oral cavity

Adverse reactions to medications are common and may have a variety of clinical presentations in the oral cavity. Targeted therapies and the new biologic agents have revolutionized the treatment of cancers, autoimmune diseases, and inflammatory and rheumatologic diseases but have also been associated with adverse events in the oral cavity. Some examples include osteonecrosis, seen with not only bisphosphonates but also antiangiogenic agents, and the distinctive ulcers caused by mammalian target of rapamycin inhibitors. As newer therapeutic agents are approved, it is likely that more adverse drug events will be encountered. This review describes the most common clinical presentations of oral mucosal reactions to medications, namely, xerostomia, lichenoid reactions, ulcers, bullous disorders, pigmentation, fibrovascular hyperplasia, white lesions, dysesthesia, osteonecrosis, infection, angioedema, and malignancy. Oral health care providers should be familiar with such events, as they will encounter them in their practice.

Acute genital ulcers in nonsexually active young girls: case series, review of the literature, and evaluation and management recommendations

Acute genital ulcers rarely occur in nonsexually active young girls. When present, they can cause significant physical and emotional distress for the patient and her parents, and prompt an evaluation for sexual abuse and sexually transmitted diseases. With this review, we aim to further characterize acute genital ulcers in nonsexually active young girls by reviewing the medical records of patients with this disorder and to offer an approach to the diagnosis, evaluation, and treatment of acute genital ulcers based on our understanding and knowledge of this condition. We retrospectively review our understanding and knowledge of acute genital ulcers in nonsexually active girls at a pediatric hospital. A review of the recent literature on acute genital ulcers and a multidisciplinary approach to the diagnosis, evaluation, and treatment of acute genital ulcers are also presented. Twelve patients presented with acute genital ulcers, 11 of which were hospitalized for evaluation and pain management. Extensive work-up failed to reveal a specific infectious or autoimmune etiology in all but one patient, who was diagnosed with acute mycoplasma pneumonia. Acute genital ulcers in nonsexually active young girls likely represent a form of idiopathic vulvar aphthosis. Evaluation of a first episode of acute genital ulcers with mild prodromal symptoms should be limited. Treatment consists primarily of supportive care and symptom relief.

Etiology and clinical and epidemiological profile of erosive and ulcerative affections of genitals

The authors present data on clinical characteristics of the course of erosive and ulcerative affections on the skin of genitals in patients who consulted a dermatovenerologist. The authors analyzed factors contributing to the onset of this pathology and having an effect on the severity of its course. They also studied the composition of microbial associations present in the discharge from lesion foci. The authors demonstrated the prevalence of a mixed infection as well as opportunistic microflora in most patients suffering from erosive and ulcerative affections on the skin of genitals.

Lipschutz ulcers: evaluation and management of acute genital ulcers in women

Acute genital ulcers are painful and distressing to women and perplexing to the providers who care for them. The differential diagnosis includes sexually and nonsexually transmitted infections, autoimmune conditions, drug reactions, and local manifestations of systemic illness. However, in many cases, no causative agent is identified, and lesions are classified as idiopathic aphthosis. In the setting of fever and acute onset of genital ulcers in girls and women, the term Lipschutz ulcers has been used to describe ulcers associated with an immunologic reaction to a distant source of infection or inflammation. The aims of this article are to review the differential diagnosis and pathogenesis of acute genital ulcers, to offer an evaluation and classification scheme, and to discuss treatment options for the dermatologist who cares for women and girls with vulvar ulcers.

Premenarchal vulvar ulceration: is chronic irritation a causative factor?

OBJECTIVE

To study the common features of the young girls with vulvar ulcerations, and to help guide physicians caring for girls with this unusual condition.

METHODS

In this retrospective study, ten patients who developed vulvar ulcerations and denied any kind of sexual contact or sexual abuse were identified. Patient information was collated from detailed history, physical, and laboratory examinations including age, menarchal status, type of clothing worn, whether history of oral aphthosis or previous vulvar ulcers had occurred, symptoms at the time of presentation, description of ulcer, laboratory studies including serologies, blood count, erythrocyte sedimentation rate, C-reactive protein, and biopsy results.

RESULTS

Despite multiple evaluations, no patient had a specific medical cause identified to account for their vulvar ulcerations. None were diagnosed with Behcet's syndrome. Seven had bilateral vulvar ulcerations, which we attribute to the practice of wearing tightly fitted pants or polyester underwear frequently. No recurrences were documented in 6 months follow-up.

CONCLUSION

Girls with vulvar ulcerations who have deny being sexually active should be thoroughly evaluated for infections, Behcet's disease, and other health problems, but, in addition, should be questioned about use of tight-fitting clothing in the perineal area. We hypothesize that chronic irritation because of tight clothing may play a role in causing vulvar ulcerations in this setting.

Vulvar ulcers in young females: a manifestation of aphthosis

STUDY OBJECTIVE

To examine the etiology, clinical course, and outcomes of non-sexually transmitted vulvar ulcers in young females.

DESIGN

A prospective cohort study of subjects referred to a tertiary center who had active vulvar ulcers and no evidence of sexually transmitted infections were evaluated with a structured clinical and laboratory protocol and followed with visits or telephone calls.

RESULTS

Twenty eligible subjects had a mean age of 14 years (range 10-19), and five were premenarchal. Nineteen reported systemic symptoms such as fever, malaise, and headache. Most ulcers were >1cm in diameter (range 0.3-5 cm) and were located on the medial aspect of the labia minora. All viral, bacterial, and fungal cultures were negative. Serologic testing for Epstein-Barr virus (EBV) infection demonstrated 10 subjects with evidence of prior infection, two with acute infection, one indeterminate, and seven negative for infection. Two subjects had evidence of possible acute cytomegalovirus (CMV) infection. Other laboratory findings were nonspecific. The median duration of pain was 10 days (range 6-30), and 75% healed by 21 days. Follow up was available for 19 subjects (median 14 months). Seven experienced recurrent ulcers 2-16 months after the initial episode, and 10 had experienced oral aphthous ulcers. None met criteria for other etiologies of vulvar ulcers reported in the literature.

CONCLUSIONS

No single infectious agent was identified as a cause of vulvar ulcers. Most cases were not temporally associated with either acute EBV or CMV infection. These ulcers are consistent with aphthous major or complex aphthosis that arise in response to acute illness.

Mucosal disease series. Number VI. Recurrent aphthous stomatitis

Recurrent aphthous stomatitis (RAS; aphthae; canker sores) is a common condition which is characterized by multiple recurrent small, round or ovoid ulcers with circumscribed margins, erythematous haloes, and yellow or grey floors typically presenting first in childhood or adolescence. RAS occurs worldwide although it appears most common in the developed world. The aetiology of RAS is not entirely clear. Despite many studies trying to identify a causal microorganism, RAS does not appear to be infectious. A genetic predisposition is present, as shown by strong associations with genotypes of IL-1beta; IL-6 in RAS patients, and a positive family history in about one-third of patients with RAS. Haematinic deficiency is found in up to 20% of patients. Cessation of smoking may precipitate or exacerbate RAS in some cases. Ulcers similar to RAS may be seen in human immunodeficiency virus disease and some other immune defects, and drugs, especially non-steroidal anti-inflammatory drugs and nicorandil may produce lesions clinically similar to RAS. Topical corticosteroids can often control RAS. However, the treatment of RAS remains unsatisfactory, as most therapies only reduce the severity of the ulceration and do not stop recurrence.

Complex aphthosis: A large case series with evaluation algorithm and therapeutic ladder from topicals to thalidomide

BACKGROUND

Recurrent aphthous stomatitis is a common problem with 20% to 50% of the population having experienced simple aphthous lesions (ie, canker sores). Complex aphthosis is the diagnosis given to patients with almost constant >3 oral aphthae or recurrent oral and genital aphthae in the absence of Behcet's disease.

METHODS

Eighty-one patients were referred to the Wake Forest University School of Medicine, Department of Dermatology from 1995 to 2001 with the diagnosis of presumptive Behcet's disease. After exclusion of patients with simple recurrent aphthous stomatitis or non-aphthous oral disease, 64 patients remained. Ten of the patients met criteria for Behcet's disease. The remaining 54 patients were evaluated and treated as patients with the diagnosis of complex aphthosis.

RESULTS

The 54 patients with complex aphthosis became the subject of this study. Twelve patients had secondary complex aphthosis with 10/12 having inflammatory bowel disease. The remaining 42 patients had primary (ie, idiopathic) complex aphthosis. The therapeutic ladder for these patients ranged from topical therapy through oral colchicine and combination oral colchicine and oral dapsone therapy to oral thalidomide therapy.

CONCLUSION

Complex aphthosis is an important condition to distinguish from Behcet's disease. Appropriate patient evaluation algorithms and treatment therapeutic ladders are proposed.

Adverse oral reactions associated with the COX-2 inhibitor rofecoxib

Rofecoxib is an inhibitor of the enzyme cyclo-oxygenase 2 (COX-2) used as an analgesic and anti-inflammatory agent especially in rheumatoid arthritis and osteoarthritis. The adverse effects are generally less than with other anti-inflammatory drugs (NSAIDs), and no oral adverse reactions have been reported in the literature. We present three cases of oral lesions caused by rofecoxib. Extensive erosions appeared, which in all cases resolved on withdrawal of the drug.

Recurrent aphthous ulcers today: a review of the growing knowledge

Recurrent aphthous ulcers represent a very common but poorly understood mucosal disorder. They occur in men and women of all ages, races and geographic regions. It is estimated that at least 1 in 5 individuals has at least once been afflicted with aphthous ulcers. The condition is classified as minor, major, and herpetiform on the basis of ulcer size and number. Attacks may be precipitated by local trauma, stress, food intake, drugs, hormonal changes and vitamin and trace element deficiencies. Local and systemic conditions, and genetic, immunological and microbial factors all may play a role in the pathogenesis of recurrent aphthous ulceration (RAU). However, to date, no principal cause has been discovered. Since the aetiology is unknown, diagnosis is entirely based on history and clinical criteria and no laboratory procedures exist to confirm the diagnosis. Although RAU may be a marker of an underlying systemic illness such as coeliac disease, or may present as one of the features of Behcet's disease, in most cases no additional body systems are affected, and patients remain otherwise fit and well. Different aetiologies and mechanisms might be operative in the aetiopathogenesis of aphthous ulceration, but pain, recurrence, self-limitation of the condition, and destruction of the epithelium seem to be the ultimate outcomes. There is no curative therapy to prevent the recurrence of ulcers, and all available treatment modalities can only reduce the frequency or severity of the lesions.

Persistent nicorandil induced oral ulceration

Four patients with nicorandil induced ulceration are described, and the literature on the subject is reviewed. Nicorandil induced ulcers are very painful and distressing for patients. Clinically they appear as large, deep, persistent ulcers that have punched out edges. They are poorly responsive to topical steroids and usually require alteration of nicorandil treatment. The ulceration tends to occur at high doses of nicorandil and all four cases reported here were on doses of 40 mg per day or greater. In these situations reduction of nicorandil dose may be sufficient to promote ulcer healing and prevent further recurrence. However, nicorandil induced ulcers have been reported at doses as low as 10 mg daily and complete cessation of nicorandil may be required.

Review article: oral ulceration--aetiopathogenesis, clinical diagnosis and management in the gastrointestinal clinic

Oral ulceration is a common complaint of patients attending out-patient clinics. The aim of this review is to provide the gastroenterologist with a differential diagnosis of oral ulceration, and a practical guide for the management of recurrent aphthous stomatitis, including topical and systemic therapy. The association of recurrent aphthous stomatitis with Behçet's disease and other systemic disorders, including coeliac disease, is discussed. Recent evidence concerning the immunopathogenesis of Behçet's disease is reviewed, including renewed interest in the role of Streptococcus sanguis and possible infectious triggering of an inappropriate immunoinflammatory response, resulting in tissue damage. The efficacy and limitations of conventional treatment for this mutisystem disorder are outlined together with the potential role of novel biological agents, such as anti-tumour necrosis factor-alpha therapy. Oral ulceration, as a manifestation of inflammatory bowel disease and a complication of drug therapy, is described. Guidance is given concerning indications for referral of patients with oral ulceration to an oral physician/surgeon for further investigations, including biopsy if appropriate.

The diagnosis and management of recurrent aphthous stomatitis: a consensus approach

BACKGROUND

Recurrent aphthous stomatitis, or RAS, is a common oral disorder of uncertain etiopathogenesis for which symptomatic therapy only is available. This article reviews the current data on the etiopathogenesis, diagnosis and management of RAS in a primary care setting.

METHODS

The authors reviewed publications on Medline from 1995 through 2000, the period since the last major reviews were published.

RESULTS

RAS may have an immunogenetic background owing to cross-reactivity with Streptococcus sanguis or heat shock protein. Predisposing factors seen in a minority include haematinic (iron, folate or vitamin B12) deficiency, stress, food allergies and HIV infection. While topical corticosteroids remain the mainstay for therapy, a number of other immunomodulatory modalities now are available.

CONCLUSIONS

There is still no conclusive evidence relevant to the etiopathogenesis of RAS, and therefore therapy can attempt only to suppress symptoms rather than to address the basic issues of susceptibility and prevention.

CLINICAL IMPLICATIONS

In the majority of patients, symptomatic relief of RAS can be achieved with topical corticosteroids alone, with other immunomodulatory topical agents or by combination therapy.

Role of drug exposure in aphthous ulcers: a case-control study

BACKGROUND

Drug-induced aphthous ulcers have been the subject of several isolated and heterogeneous case reports for the last three decades.

OBJECTIVES

To perform a case-control study to evaluate the risks linked to drug exposure in aphthous ulcers.

METHODS

Eighty patients with typical clinical patterns of aphthous ulcers and 152 control patients who had had consultations for skin tumours were studied. A standardized questionnaire, concerning clinical features, life-style and medications taken during the last month, was completed for each patient.

RESULTS

Case patients had a much higher intake of medications than control patients, respectively, 5.1 and 2. 8 medications per patient (P < 0.0001). Multivariate paired analysis showed an association between aphthous ulcers and two classes of drugs: non-steroidal anti-inflammatory drugs (P < 0.001) and beta-blockers (P = 0.002). Smoking could have a protective effect against aphthous ulcers (P < 0.001).

CONCLUSIONS

Previous case reports and the results of this study suggest a real link between beta-blockers and aphthous ulcers. Our study did not confirm a role of other drugs but a few interesting case reports with positive reintroduction have to be considered. These results could be beneficial for patients, as healing may occur when the incriminated drug is discontinued.

Behçet's disease and complex aphthosis

Behçet's disease is a complex multisystem disease diagnosed by means of clinical criteria. Clinical features include oral and genital aphthae, pustular vasculitic cutaneous lesions, and ocular, gastrointestinal, and vascular manifestations. We believe that complex aphthosis, characterized by oral or oral and genital ulcers, may be a forme fruste of Behçet's disease. Although the pathogenesis of both Behçet's disease and complex aphthosis remain unknown, immune factors, infectious agents, and effector mechanisms are implicated. Treatment is based on the severity of systemic involvement and includes topical therapies as well as colchicine, dapsone, thalidomide, and immunosuppressive agents.

Recurrent aphthous stomatitis

Recurrent aphthous stomatitis (RAS) is one of the most common oral mucosal disorders. Nevertheless, while the clinical characteristics of RAS are well-defined, the precise etiology and pathogenesis of RAS remain unclear. The present article provides a detailed review of the current knowledge of the etiology, pathogenesis, and management of RAS.

Quantitative assessment of mast cells in recurrent aphthous ulcers (RAU)

Previous studies on the frequency of mast cells (MCs) in recurrent aphthous ulcers (RAU) have yielded conflicting results. Monoclonal antibodies specific for tryptase (AA1) and anti-IgE (polyclonal antibody) were used to identify density and distribution of MCs in an immunohistochemical study of RAU (n=15), induced oral traumatic ulcers (TUs) (n=9), and control clinically healthy oral mucosa (n=15). Results were quantified by means of a VIDAS image analyzer. In all sections studied, IgE-positive cells showed similar frequency and distribution to tryptase-positive MCs. In RAU lesions, numerous tryptase-positive MCs were found in the sub-epithelial lamina propria, but MC numbers in the epithelium were low and present only in some RAU biopsies. MCs were also more numerous in RAU-inflammatory infiltrates (118+/-31 cells/mm2) than those seen in TU-inflammatory infiltrates (75+/-18 cells/mm2, P<0.001). MC activation/degranulation, as judged by diffuse extracellular tryptase staining, was a common feature within RAU-inflammatory infiltrates and at RAU-inflammatory infiltrates-connective tissue interfaces, which were often associated with connective tissue disruption. MC counts in the RAU connective tissue, lateral to the inflammatory infiltrates, were significantly greater than in the connective tissue of TUs and of control biopsies (124+/-36 vs 73+/-13 vs 69+/-21 cells/mm2, respectively; P<0.001). Overall, MCs were significantly increased in aphthae (116+/-26 cells/mm2) compared with TU lesions (72+/-11 cells/mm2, P<0.001) and controls (71+/-16 cells/mm2, P<0.001). In conclusion, MC numbers are increased in a typical topographical pattern, and the local MCs show signs of activation/degranulation suggesting active involvement of this cell type in RAU pathogenesis.