CONTINUING MEDICAL EDUCATION
Treatment of Severe, Recalcitrant, Major
Aphthous Stomatitis With Adalimumab
Justin Vujevich, MD; Matthew Zirwas, MD
To understand recurrent aphthous stomatitis (RAS) to better manage patients with the condition
Upon completion of this activity, dermatologists and general practitioners should be able to:
1. Describe the 3 types of RAS lesions.
2. Discuss the pathogenesis of RAS.
3. Explain the treatment options for RAS.
CME Test on page 104.
This article has been peer reviewed and
approved by Michael Fisher, MD, Professor of
Medicine, Albert Einstein College of Medicine.
Review date: July 2005.
This activity has been planned and implemented
in accordance with the Essential Areas and Policies
of the Accreditation Council for Continuing Medical
Education through the joint sponsorship of Albert
Einstein College of Medicine and Quadrant
HealthCom, Inc. Albert Einstein College of Medicine
is accredited by the ACCME to provide continuing
medical education for physicians.
Albert Einstein College of Medicine designates
this educational activity for a maximum of 1
category 1 credit toward the AMA Physician’s
Recognition Award. Each physician should
claim only that credit that he/she actually spent
in the activity.
This activity has been planned and produced in
accordance with ACCME Essentials.
Dr. Vujevich reports no conflict of interest. Dr. Zirwas is a consultant for and has received an unrestricted
educational grant from Amgen. The authors discuss off-label use of adalimumab, etanercept, pentoxifylline,
and thalidomide. Dr. Fisher reports no conflict of interest.
We describe an 18-year-old man with a 7-year
histor y of severe major aphthous stomatitis
refractory to multiple standard therapies who
responded completely to therapy with adalimumab, a fully humanized monoclonal antibody
against tumor necrosis factor (TNF-).
Accepted for publication April 18, 2005.
Dr. Vujevich is a dermatology resident, and Dr. Zirwas is Assistant
Professor of Dermatology, both in the Department of Dermatology,
University of Pittsburgh Physicians, Pennsylvania.
Reprints: Matthew Zirwas, MD, Falk Medical Bldg, 3601 Fifth Ave,
5th Floor, Pittsburgh, PA 15213 (e-mail: [email protected]).
ecurrent aphthous stomatitis (RAS) is a
common disease of the oral mucosa, affecting
approximately 1 in 5 individuals during their
lifetime.1 Clinically, these lesions manifest as painful
erythematous erosions or ulcerations typically on
RAS lesions are classified into 3 groups, based
on size. Minor recurrent aphthous ulcers, the most
common variety, are painful ulcers less than 1.0 cm
in diameter that occur on nonkeratinized mucosa.
The second class, major recurrent aphthous ulcers,
are similar in clinical appearance but are larger
(1.0 cm), more painful, longer lasting, and heal
with scarring. The third group is herpetiform RAS.
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Major Aphthous Stomatitis With Adalimumab
These painful ulcers frequently cluster on the lower
lip, heal without scarring, occur more often in
women, and have a later onset of presentation.
The etiology of RAS is poorly understood and
appears to be multifactorial. Predisposing factors such
as heredity,2 trauma,3 emotional stress,4 reactivation
of latent virus,5 hypersensitivity to certain foods,6 and
immunoglobulin A (IgA) deficiency7 may contribute
to the pathogenesis of individual cases.
RAS is typically an isolated finding but may
occur as one manifestation of a systemic disease.
Associated diseases include Behçet syndrome;
Reiter syndrome; vitamin deficiency; inflammatory
bowel disease; mouth and genital ulcers with
inflamed cartilage (MAGIC) syndrome; periodic
fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome; Sweet syndrome; and cyclic
neutropenia.8 Although the immunopathogenesis
of RAS is unknown, most evidence suggests RAS is
a T-cell–mediated disorder resulting in the secretion of cytokines that have a cytotoxic effect on
oral mucosa cells.
There appears to be an abnormality of cytokine
expression in patients with RAS, with tumor
necrosis factor (TNF-) being one of the overexpressed cytokines. Borra et al9 utilized complementary DNA microarray analysis to demonstrate a
helper T cell subtype 1–predominant immune
response profile in aphthous ulcer specimens compared with control oral mucosa. Buno et al10 examined the pattern of cytokine messenger RNA
expression in lesional and normal mucosa from
patients with RAS, and reported higher levels of
the messenger RNAs of the helper T cell subtype 1
proinflammatory cytokines interleukin 2, interferon , and TNF- in lesional biopsy specimens of
patients with RAS compared with mucosa from
healthy controls. Natah et al11 reported that TNF-–
containing cells were more numerous in RAS oral
specimens compared with control oral mucosa.
Finally, Taylor et al 12 demonstrated enhanced
release of TNF- by peripheral blood monocytes in
patients with RAS.
An 18-year-old man was referred to our clinic with
a 7-year history of severe oral ulcerations. The
lesions were extremely painful, were present on an
essentially continuous basis, and healed with scarring. The ulcerations interfered with eating, drinking, and speaking. No relationship to trauma or
food intake was noted.
The results of a review of symptoms were otherwise negative. Specifically, the patient had no
gastrointestinal tract symptoms, fevers or chills,
ocular symptoms, genital ulcerations, or risk
factors for human immunodeficiency virus. No
amalgam or acrylic material was present in the
mouth. Results of a physical examination revealed
ulcers 1- to 2-cm in diameter with fibrinous bases
and erythematous borders involving the buccal
and labial mucosa (Figure, A), tongue, soft palate,
Results of an oral biopsy demonstrated a
mucosal ulceration with nonspecific inflammation. Test results measuring complete blood count;
serum vitamins B1, B2, B6, and B12; serum folate
and iron levels; and serum antinuclear antibodies
were within reference range. The diagnostic evaluation also included a normal colonoscopy and
esophagogastroduodenoscopy, with normal random mucosal biopsy results and a normal funduscopic evaluation.
The patient’s previous therapies included highpotency topical steroids, topical tacrolimus ointment, chlorhexidine rinses, topical tetracycline,
topical lidocaine, oral colchicine (0.6 mg twice
daily), oral dapsone (125 mg/d), oral azathioprine
(250 mg/d), oral sulfasalazine, and oral prednisone
ranging in doses of 10 to 60 mg. Only oral prednisone had been effective, and the dose required to
ameliorate symptoms sufficiently to allow adequate oral intake and speech had averaged 40 mg/d
over the previous 3 years, with no periods off
prednisone during that time. Despite this dose of
prednisone, an unintentional weight loss of 40 lb
occurred secondary to decreased oral intake.
Based on the in vitro data showing up-regulation
of TNF- in RAS and a prior case report describing
use of etanercept for RAS,13 we decided to undertake
a therapeutic trial of adalimumab, a monoclonal,
fully human anti–TNF- antibody, at a dosage of
40 mg injected subcutaneously every other week.
Two weeks after the first subcutaneous injection, our patient showed a 90% clinical improvement of ulcerations (Figure, B). Over the next
several weeks, all remaining ulcerations had completely healed. After 4 months, our patient had no
recurrence of ulcerations, and his therapy with
oral prednisone was discontinued for the first time
in 3 years. Our plan is to continue biweekly injections for a 6-month period, and if there is no
recurrence of ulceration during this time, the
interval between subcutaneous injections will be
lengthened until the minimum required frequency
of injections is achieved.
Adalimumab is a recombinant, fully humanized
IgG1 monoclonal antibody that binds specifically
Major Aphthous Stomatitis With Adalimumab
to TNF-, preventing the cytokine from binding to
its p55 and p75 receptors and therefore neutralizing the activity of the cytokine.14 It is approved by
the US Food and Drug Administration for use in
the treatment of moderate to severe rheumatoid
arthritis in adults who have had an inadequate
response to disease-modifying antirheumatic drugs.
The recommended dosage in these patients is
40 mg injected subcutaneously every other week.
Anti–TNF- therapies have shown success in
the treatment of RAS. Pentoxifylline has been
shown to reduce the number of recurrent aphthous
ulcers in an open clinical trial.15 Thalidomide has
been reported to achieve up to a 50% remission in
patients with recurrent aphthous ulcers in one
crossover study versus placebo.16
Recent reports have shown successful treatment of RAS with TNF- monoclonal antibody
blocking agents. Robinson and Guitart13 reported
a 50-year-old woman with partial improvement in
chronic RAS after biweekly subcutaneous injections of etanercept, a dimeric fusion protein combining the extracellular portion of the human
TNF receptor (p75) linked to the Fc portion of
IgG. Kaufman et al17 reported dramatic improvement of RAS in patients with Crohn disease using
a single 5 mg/kg intravenous infusion of infliximab, a chimeric TNF- monoclonal IgG1 antibody composed of the mouse TNF- receptor
linked to the Fc portion of IgG.
To our knowledge, this is the first report demonstrating effectiveness of adalimumab for the treatment of RAS. There are several advantages to
using this agent. First, it binds to TNF- with
greater affinity than does etanercept,18 providing a
more complete blockage of TNF-. Second, it is
dosed subcutaneously, making it more convenient
for patients than infliximab, which requires an
intravenous infusion. Finally, it is a fully humanized product, so the probability of neutralizing
antibody development is low.
In summary, we present a patient with severe,
debilitating major RAS who was recalcitrant to
multiple standard therapies. The patient’s lesions
responded dramatically to subcutaneous adalimumab injections. We believe this agent has significant potential as a novel therapy for severe
cases of RAS.
Major aphthous ulcer on the buccal and labial mucosa
before (A) and 14 days after (B) the patient’s first
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