GPAtlas🧭 When to suspect
Recurrent aphthous stomatitis (RAS), or aphthous ulcers, is the most common disease of the oral mucosa, affecting up to 1 in 4 people. It usually begins in childhood or adolescence and tends to settle with age. The hallmark is recurrent crops of painful, round or oval ulcers with a yellow-grey floor and an erythematous halo, appearing on non-keratinised (movable) mucosa – buccal and labial mucosa, floor of mouth, and the ventral/lateral tongue. They characteristically spare the hard palate, attached gingiva and dorsum of the tongue. Diagnosis is clinical, and the great majority are benign and self-limiting.
There are two jobs in primary care. The first is to recognise the benign recurrent pattern and treat symptomatically. The second – the one that matters most – is to never dismiss a single, persistent ulcer: an unexplained ulcer lasting more than 3 weeks needs a suspected cancer pathway referral. Suspect a secondary cause when ulcers begin in adulthood, are unusually severe or frequent, or come with systemic features – think haematinic deficiency, coeliac disease, inflammatory bowel disease or Behçet's disease.
| Subtype | Typical appearance | Course |
|---|---|---|
| Minor (most common) | Crops of small ulcers, each < 10 mm, on non-keratinised mucosa | Heal in 10–14 days, no scarring |
| Major | One to three larger ulcers, > 10 mm, any site including soft palate/fauces | Heal over weeks, may scar |
| Herpetiform | 10–50 pinpoint ulcers that may coalesce; not caused by herpes virus | Heal in 10–14 days |
Source: NICE · NICE NG12
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