Mouth Ulcers and Sweet’s Syndrome

Updated 31/03/17.

Does Sweet’s syndrome cause mouth ulcers?

Yes. Occasionally, Sweet’s syndrome can cause mouth/oral ulcers (aphthous-like ulcers), but this is a symptom that is more commonly associated with the similar condition, Behcet’s syndrome.

Can Sweet’s syndrome cause other mouth problems?

Yes. On rare occasions, Sweet’s syndrome can cause other mouth problems, and also affect the throat. Symptoms include:

  • Cracks or fissures on the corners of the mouth (Contrucci and Martin, 2015).
  • Lesions on the inside of the lips (haemorrhagic bullae and vesicles, and necrotic nodules) (Cohen, 2007).
  • Lesions on the gums (haemorrhagic bullae and vesicles).
  • Necrotizing ulcerative periodontitis.
  • Enlargement of the gums (gingival hyperplasia) (Ibid).
  • Lesions on the tongue (aphthous-like ulcers, ulcers, and macerated papules) (Cohen, 2007; Kasirye et al, 2011: 135) .
  • Tongue pain, and swollen or enlarged tongue in association with lesions (Cohen, 2007; Contrucci and Martin, 2015; Kasirye et al, 2011: 135).
  • Lesions on the roof of the mouth (macerated papules, individual and grouped pustules, ulcers, and bullae) (Cohen, 2007; Contrucci and Martin, 2015).
  • Lesions affecting the pharynx (individual and grouped pustules) (Cohen, 2007).
  • Lesions on the inside of the cheeks (aphthous-like ulcers, and ulcers).
  • Inflammation of the saliva glands in the cheeks (parotitis) and associated cheek swelling (Jo et al, 2012).
  • Throat pain, painful swallowing, and hoarseness (Contrucci and Martin, 2015).

Read more about the symptoms of Sweet’s syndrome here.

Can mouth ulcers be treated or managed?

Yes. Mouth ulcers can be treated or managed, and the UK charity, the Behcet’s Syndrome Society (BSS), has put together a patient-information-leaflet to show you how. The information in this leaflet has been written for those with Behcet’s syndrome, but is also relevant to those with Sweet’s syndrome.


Information taken from the Behcet’s Syndrome Society leaflet – Behcet’s Disease and Mouth Ulcers (Birmingham Centre of Excellence, 2013).

Treatment.

General good oral hygiene is important with Behcet’s disease (*and Sweet’s syndrome), even when the mouth or gums are painful. Rinsing with mouthwash alone will not remove the dental plaque and is no substitute for brushing the teeth and flossing.

Typical adult toothpastes include detergents such as sodium lauryl sulphate (SLS) and flavouring agents that can exacerbate pain associated with oral ulceration. Toothpastes without SLS or prepared specifically for the ‘sore mouth’ are available. An alternative option is to use a children’s toothpaste. Toothpastes used by adults should include 1450 ppm fluoride.

Before considering the options listed below, you should discuss topical solutions with your specialist or doctor. Some of the remedies listed below are not licensed specifically for use in Behcet’s disease (*doxycycline and colchicine are recognised treatments for Sweet’s syndrome) so will need consideration by your medical professional. Many are prescription-only and will require ongoing monitoring.

Relief of pain.

Topical analgesia for oral ulceration is available as mouthwash and spray (Difflam). The mouthwash potentially allows more parts of the mouth to be reached than the spray but is less portable. A normal dose would be to rinse or gargle with 15 ml of the mouthwash every 1–3 hours as needed and spit it out. The preparation contains 10% alcohol, which can cause stinging when used with a sore mouth. Dilution with an equal volume of water can help. For the spray preparation, 4–8 sprays should be directed onto the affected area every 1–3 hours as needed.

Relief of inflammation and reduction in ulceration.

Topical corticosteroids reduce inflammation and are the mainstay of topical treatment. All topical corticosteroid therapies are best applied as soon as the ulcer starts to develop and should be continued until the ulcer has completely disappeared. A wide range of topical corticosteroids may be considered and food and drink should be avoided for at least 30 minutes following application.

For the treatment of a single or low number of ulcers.

Mucoadhesive buccal tablets (previously known as Corlan pellets) can be placed on the ulcers and allowed to dissolve. This should be done up to four times daily. However, some patients may find the tablets difficult to position in the correct place.

Alternatively, an aerosol preparation such as a steroid inhaler used in the management of asthma or allergic rhinitis (e.g. hay fever) may be considered. The aerosol can be sprayed directly onto ulcers. Suitable inhalers are beclometasone metered-dose inhaler 50–100 micrograms sprayed twice daily onto the affected area or fluticasone propionate aqueous spray 50 micrograms, 2 puffs sprayed on to the ulcers three times daily.

For treating several ulcers.

Corticosteroid mouthwashes can be used where there is widespread development of crops of ulcers. Betamethasone soluble 500 microgram tablets are licensed for the management of oral ulcers. One tablet should be dissolved in 10–15 ml of warm water and then gargled ensuring affected parts of the mouth are covered for up to 4 minutes. The solution should not be swallowed. The mouthwash should be used up to three times a day. Alternatively, soluble prednisolone 5 mg tablets dissolved in 10–15 ml of warm water can be used up to three times a day.

Protective barriers.

Mucosal coating agents are used to physically cover ulcerated areas to reduce unpleasant symptoms associated with activities such as speaking, smiling swallowing or yawning.

Pastes.

Carmellose sodium (Orabase) can be used to protect the sore areas of the mouth. It should be applied sparingly directly onto the ulcer when required. Application can be difficult to the tongue and the back of the mouth.

Topical gels.

Gelclair is a viscous gel specifically formulated to aid the management of inflammation of the oral mucosa. The gel can be used as a mouthwash up to three times daily after dilution or applied directly to the affected site using a clean finger or swab such as a cotton bud. The mouthwash is prepared by diluting the contents of one sachet with 3 tablespoons of water. The solution is then rinsed around the mouth for 1 minute and provides a protective coat over the mucosa.

Anti-microbial agents.

Anti-microbial agents are used to control pain by reducing the secondary infection associated with mucosal ulceration.

Chlorhexidine mouthwash, gel or spray.

Chlorhexidine has a broad anti-microbial spectrum. Preparations are licensed for the management of aphthous ulcers.

For chlorhexidine 0.2% mouthwash, 10 ml of solution should be rinsed around the mouth for 1 minute twice daily and then spat out. Alternatively, an oral spray – Corsodyl (chlorhexidine 0.2%) – may be used with up to 12 applications of spray used twice daily. Chlorhexidine gel preparations can be applied directly to the ulcer or brushed on the teeth once or twice daily. Preparations available include Corsodyl gel (chlorhexidine 1%) and Curasept gel (chlorhexidine 5%).

A number of chlorhexidine preparations contain alcohol, which can irritate the oral mucosa. However, alcohol-free mouthwashes can be found, including Corsodyl, Curasept and Periogard. The Curasept gel formulation is also alcohol-free.

Doxycycline.

Doxycycline has antibacterial and anti-inflammatory properties and can be used when the use of chlorhexidine has failed. Its main value in treating mouth ulcers comes from its anti-inflammatory action. The contents of one doxycycline 100 mg capsule should be dissolved in 10–15 ml water. Again, the solution should be held in the mouth for up to 4 minutes, ensuring that the solution comes into contact with the affected parts of the mouth. This should be done at least four times a day for 3 days. The solution should not be swallowed, and food and drink should be avoided for 30 minutes after use of the preparation. Prolonged use should be avoided, as this can increase the risk of oral infections such as candidiasis (thrush).

Colchicine.

For recurrent oral ulceration that has failed to respond to topical treatments alone, oral colchicine may be prescribed by your doctor.

* Additional notes added to the text – Michelle Holder, Sweet’s Syndrome UK.


For patients in the United States with an autoinflammatory condition, including Sweet’s syndrome.

Information taken from the SAID Support blog – Mouth Ulcer Treatment and Prevention (Tousseau, 2013).

Prescription Magic Mouthwash.

Magic mouthwash (*not available in the UK) is a prescription mouthwash that you use to rinse and then spit. It primarily contains lidocaine, which numbs the mouth. There are different brands available that may also contain hydrocortisone to reduce inflammation, the antifungal medication nystatin, an antibiotic, and/or the antacid magnesium hydroxide to coat the mucus membranes inside the mouth.

Milk of Magnesia and Liquid Benadryl.

This is a liquid mouthwash you can make at home, but discuss this with your doctor before you begin using this treatment. Mix 1/2 teaspoon each of milk of magnesium and liquid Benadryl. Swish it in the mouth and then spit it out. Do not drink it. Some people mix it up, and squirt it into the mouth with an oral medicine syringe to coat the mouth, then spit it out.

Hydrogen Peroxide and Milk of Magnesia.

Dab a drop of hydrogen peroxide mixed with water directly on the ulcer with a cotton swab. The National Institutes of Health (NIH) recommends mixing one part hydrogen peroxide to one part water followed by a dab of Milk of Magnesia directly onto the sore. You can do this three to four times a day.

B Vitamins.

Folic acid and vitamin B12 deficiencies can cause mouth ulcers. A daily B vitamin supplement may help reduce or prevent mouth sores.

*Sweet’s syndrome-related mouth ulcers are not caused by vitamin deficiency, but a daily B vitamin may help to reduce your overall risk of developing non-Sweet’s syndrome-related mouth ulcers.

A Benzocaine Warning.

In 2011, the FDA released a warning that using products containing benzocaine could lead to methemoglobinemia, a rare blood disorder. Most of the cases reported were in children under that age of two who were treated with benzocaine gel products for teething pain. Adult cases have also been reported. The FDA recommends that benzocaine products not be used on children younger than two without medical supervision.

*In the UK, the National Institute for Health and Care Excellence (NICE) does not recommend the use of benzocaine or any other topical anaesthetic in children under the age of two, unless on the advice of a health professional or under medical supervision (CKS, 2014).

* Additional notes added to the text – Michelle Holder, Sweet’s Syndrome UK.


New research.

Anakinra.

Anakinra (Kineret) is a useful treatment in refractory (chronic or persistent, or difficult-to-treat) Sweet’s syndrome and other neutrophilic dermatosesand autoinflammation of unknown cause (Kluger et al, 2011: Simon et al, 2014). The results of a recent trial have also shown that anakinra at an optimal dose of 200mg daily is partially effective in the treatment of resistant oral and genital ulcers in Behcet’s syndrome (Grayson et al, 2017).


References.

Birmingham Centre of Excellence (2013) Behcet’s Disease and Mouth Ulcers. Behcet’s Syndrome Society (PDF).

CKS: Clinical Knowledge Summaries (2014) Teething – Topical Anaesthestics. NICE: National Institute for Health and Care Excellence (online).

Cohen, P. (2007) Extracutaneous Manifestations: Table 4. In Sweet’s syndrome – a comprehensive review of an acute febrile neutrophilic dermatosis, Orphanet Journal of Rare Diseases (online).

Contrucci, R. and Martin, D. (2015) Sweet syndrome: A case report and review of the literature. ENT Journal, July;94(7):282-284 (online). Sign-up to the ENT Journal for free to access the full article.

Grayson, P. Yazici, Y., Merideth, M., Sen, H., Davis, M., Novakovich, E., Joyal, E., Goldbach-Mansky, R. and Sibley, C. (2017) Treatment of mucocutaneous manifestations in Behçet’s disease with anakinra: a pilot open-label study. Arthritis Research & Therapy, Mar 24;19(1):69 (online).

Jo, M., Lim, Y., Shin, H., Choe, J., Seul, J. and Jang T. (2012) A Case Report of Sweet’s Syndrome with Parotitis. Archives of Plastic Surgery, Jan;39(1):59-62 (online).

Kasirye, Y., Danhof, R., Epperla, N. and Garcia-Montilla, R. (2011) Sweet’s Syndrome: One Disease, Multiple Faces. Clinical Medicine & Research, Nov;9(3-4):134-136 (online).

Kluger, N., Gil-Bistes, D., Guillot, B. and Bessis, D. (2011) Efficacy of anti-interleukin-1 receptor antagonist anakinra (Kineret®) in a case of refractory Sweet’s syndrome. Dermatology (Basel, Switzerland), May;222(2):123-7 (PubMed).

Simon, A. et al (2014) Autoinflammation of Unknown Cause. AUTOINFLAMMATION.EU (online).

Tousseau, J. (2013) Mouth Ulcer Treatment and Prevention. SAID Support (online).

Other information.

Ngan, V. and Oakley, A. (2016) Aphthous Ulcers (online). Initially published in 2003, and updated by Professor A. Oakley, Jan 2016. Accessed 30/03/17.

© 2012-2017 Sweet’s Syndrome UK

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