Potassium-competitive acid blockers (P-CABs) are the first mechanistically distinct oral acid suppressants to challenge proton pump inhibitors (PPIs) in routine practice. By reversibly inhibiting gastric H+/K+-ATPase without requiring acid activation, they provide rapid onset of action, durable 24-hour acid control, and less dependence on meal timing and CYP2C19 variability. These pharmacologic features are clinically relevant in acid-related disorders, but the clinical evidence is not uniform across individual compounds. Within the class, the most mature efficacy and safety data are derived from vonoprazan, whereas newer agents, including zastaprazan, remain supported by a more limited evidence base. In erosive esophagitis, randomized trials indicate that P-CABs are effective acid suppressants, but compound-specific conclusions are more appropriate than broad assumptions of interchangeable class effects. For zastaprazan specifically, phase III data show that 20 mg is noninferior to esomeprazole 40 mg at week 8, with higher week-4 healing rates in a predominantly low-grade population. By contrast, no clinical trials have directly evaluated any P-CAB for stress ulcer prophylaxis in critically ill adults. Current intensive care unit guidelines continue to support PPIs or histamine-2 receptor antagonists for patients at high risk of stress-related gastrointestinal bleeding, and pantoprazole remains the best-established benchmark. This review integrates mechanistic, pharmacokinetic, efficacy, safety, regulatory, and guideline data relevant to P-CABs, with particular attention to zastaprazan, while distinguishing compound-specific findings from broader class-level considerations.

Bullous systemic lupus erythematosus (BSLE) is a rare blistering manifestation of systemic lupus erythematosus (SLE), characterized by widespread tense bullae resulting from autoantibodies against type VII collagen. It is predominantly seen in women and is exceptionally rare in pediatric males. We report a case of a 14-year-old South Asian male with recurrent tense blisters over the trunk, face, extremities, palms, and mucosa, alongside systemic features including photosensitivity, arthralgia, oral ulcers, and significant renal involvement. Laboratory findings revealed proteinuria, hypoalbuminemia, low complement levels, and positive antinuclear antibodies. Skin biopsy revealed subepidermal blisters with neutrophilic infiltrates, and direct immunofluorescence (DIF) demonstrated linear IgG, IgA, IgM, and C3 deposition at the basement membrane. Renal biopsy revealed membranous glomerulonephritis along with positive DIF showing IgG and C3 deposition. Treatment with corticosteroids, dapsone, and mycophenolate mofetil led to significant clinical improvement. This case emphasizes the need for a high index of clinical suspicion in young males presenting with blistering dermatoses, as BSLE may serve as an early marker of active systemic disease, particularly lupus nephritis. BSLE is considered an important diagnostic red flag, especially in the pediatric population, because its appearance may signal active underlying systemic disease, as seen in our patient with lupus nephritis. Sudden development of widespread tense blisters may coincide with systemic disease flares. Early recognition and aggressive management with immunosuppressants, along with close renal monitoring and long-term follow-up, are essential to reduce irreversible cutaneous and renal complications.

Amyloidosis is characterized by extracellular deposition of amyloid material in various tissues and organs. Deposition of amyloid in the tongue is rare but often occurs in multiple myeloma. Here we present the case of a 44-year-old woman under treatment for multiple myeloma who complained of lateral tongue pain. Intraoral examination revealed an ill-defined, firm, whitish swelling with an ulcerated surface on the bilateral borders of the tongue. Histopathological analysis revealed a lympho-mononuclear infiltration in the lamina propria with the presence of acellular and amorphous material positive for Congo red staining. Further examination revealed amyloidosis in a cervical mass associated with neural compression. Thorough examination of the oral cavity in patients with multiple myeloma is critical for early detection of amyloidosis. A biopsy is mandatory to confirm the diagnosis, thereby facilitating intervention and management if necessary.

Ulcerative giant breast cancer (UGBC) presents management challenges including uncontrolled bleeding, infection, and rapid tumor progression, which often culminate in life-threatening complications. Traditional spatially fractionated radiotherapy (SFRT) like lattice radiotherapy (LRT) offers potential for palliating bulky tumors, although its application in UGBC remains limited. We report a 51-year-old woman with a hormone receptor-positive, human epidermal growth factor receptor 2 (HER2)-negative stage IIIC UGBC (20.5 cm × 6.98 × 18.17 cm ulcerative lesion). Treatment consisted of modified lattice radiotherapy (mLRT: 15 Gy×3 fractions), followed by volumetric-modulated arc therapy (VMAT: 36 Gy/20 fractions) and systemic therapy (exemestane, capecitabine, CDK4/6 inhibitor). Rapid hemostasis was achieved within 5 days, with 39.7% tumor reduction at week 4 and progressive wound healing. At 3-month follow-up after the completion of mLRT and prior to definitive radiotherapy, the tumor had achieved a 61.8% volume reduction, with only minimal residual disease remaining. The radiation-induced skin reaction gradually alleviated with symptomatic treatment. This case demonstrates mLRT's efficacy in achieving rapid hemostasis and significant tumor regression for chemotherapy-refusing UGBC patients. The combined approach of mLRT, VMAT, and systemic therapy provides a promising multidisciplinary strategy for symptom control and quality-of-life improvement. Further prospective studies are needed to validate these findings.

Pemphigus vulgaris (PV) is an autoimmune blistering disease that may present predominantly with mucosal involvement and is frequently misdiagnosed as infectious or inflammatory conditions. We describe a 72-year-old Filipino woman with a 3-month history of painful oral and genital ulcerations and subsequent flaccid bullae who was initially diagnosed and treated sequentially for candidiasis, disseminated herpes zoster infection, and Behçet's disease based on International Criteria for Behçet's Disease scoring. Despite multiple antimicrobial therapies, her symptoms progressed. Definitive evaluation revealed intraepidermal acantholysis on histopathology and intercellular IgG and C3 deposition in a characteristic "fishnet" pattern on direct immunofluorescence, with positive desmoglein 1 and 3 antibodies, confirming PV. Prompt initiation of systemic corticosteroids led to rapid clinical improvement. This case underscores how diagnostic anchoring and reliance on classification criteria can delay recognition of autoimmune blistering disease, highlighting the need for early biopsy and direct immunofluorescence in persistent mucocutaneous ulceration.

Oral mucosal ulcers sustain a persistent inflammatory and oxidative microenvironment that interferes with epithelial repair and delays healing. Although hyaluronic acid (HA) is used in oral wound management due to its biocompatibility and hydrating properties, its biological activity is highly context-dependent and can be compromised under inflammatory conditions. In contrast, N-acetyl-L-cysteine (NAC) is a well-established antioxidant with documented anti-inflammatory effects, yet its rapid clearance limits its effectiveness when applied locally. In this study, the effects of HA and NAC, individually and in combination, on metabolic activity and inflammatory responses of TNF-α-stimulated human gingival keratinocytes were evaluated. In parallel, the individual immobilization of HA or NAC onto plasma-activated decellularized extracellular matrix (dECM) films was investigated as a materials-oriented approach for potential localized intraoral applications. NAC significantly attenuated TNF-α-induced IL-6 and IL-8 secretion, reducing both cytokines by approximately 99%, while preserving keratinocyte metabolic activity. HA displayed limited immunomodulatory effects. The combined HA + NAC condition did not improve the response compared with NAC alone. Plasma treatment enabled stable individual grafting of HA and NAC onto dECM films, and both functionalized surfaces retained chemical stability under saliva-like conditions. Collectively, these findings identify NAC as the most effective anti-inflammatory candidate under the tested cellular conditions and support plasma-functionalized dECM films as a feasible platform for future biological evaluation in intraoral applications.

Recurrent aphthous ulcers (RAU) is a common idiopathic oral mucosal disorder marked by painful, round ulcers on non-keratinized tissues such as the buccal, labial, and lingual mucosa. These recurrent lesions impair oral function and quality of life. However, systemic treatments, such as oral or injectable medications, often exhibit limited efficacy and are associated with notable adverse effects. The effectiveness of topical treatments is often limited by the barrier properties of the oral epithelium and the dynamic oral environment. Continuous salivary flow and mechanical forces from speaking and mastication dilute, remove, or prevent adequate absorption of locally applied drugs, contributing to inconsistent therapeutic outcomes. Biomedical microneedles offer a promising alternative for delivering drugs to the oral mucosa, overcoming many shortcomings of conventional topical, oral, and injectable methods. Their capacity to painlessly breach superficial barriers enhances drug bioavailability while minimizing discomfort, bleeding, and infection risk. These features collectively improve patient adherence and provide a more acceptable treatment modality for recurrent conditions such as RAU. With rapid advancements in microneedle materials, fabrication techniques, and drug-loading strategies, emerging microneedle-based delivery systems are increasingly adaptable to the unique environment of the oral cavity. These include superior mucosal adhesion to prevent detachment, sustained drug release for prolonged retention, penetration into the pseudomembrane to bypass physical barriers, and the potential for designing multifunctional and smart-responsive systems. Such characteristics render microneedle-based systems a more acceptable and effective approach for managing recurrent conditions like RAU. This review provides an updated framework for understanding the potential of innovative microneedle technologies in the management of recurrent aphthous ulcers and highlights future opportunities for clinical translation.

Diabetic oral ulcers represent a refractory clinical challenge characterized by a distinct pathological microenvironment that severely compromises mucosal regeneration. The healing process in these lesions is frequently stalled by a self-perpetuating cycle of persistent bacterial colonization, excessive reactive oxygen species accumulation, and sustained inflammatory responses. However, conventional hydrogel dressings predominantly offer passive physical protection, lacking the dynamic responsiveness required to actively coordinate infection control with microenvironmental remodeling. Here, we show the design of an injectable and self-healing polysaccharide hydrogel (DAP1) engineered with polydatin-loaded copper-doped zeolitic imidazolate framework-8 nanozymes for infection-responsive wound management. Our results demonstrate that this platform undergoes microenvironment-responsive degradation under simulated pathological conditions, enabling the release of therapeutic components that contribute to antibacterial activity, oxidative stress alleviation, and tissue repair. Furthermore, in a diabetic rat oral ulcer model, the hydrogel significantly accelerates mucosal healing and tissue reconstruction by effectively suppressing inflammatory interleukin-6 expression and promoting robust neovascularization. Collectively, this study presents a microenvironment-responsive therapeutic platform that integrates infection control with regenerative repair, offering a promising strategy for the clinical treatment of refractory diabetic oral wounds.

Cutaneous small-vessel vasculitis (CSVV) is a rare skin vasculitis that mainly affects small blood vessels and is often caused by certain drugs or diseases. When the condition is severe, skin ulcers may occur, accompanied by severe pain, which can affect daily life. This article reports a case in which the patient had a poor response to conventional corticosteroid therapy, with the condition continuing to deteriorate. Following 3 months of combination therapy with oral upadacitinib, the skin lesions nearly healed completely. This provides a new perspective for the treatment of CSVV and offers clinicians an additional treatment option.

Chronic leg ulcers are a significant source of morbidity in elderly patients, particularly those with multiple comorbidities. The most common etiologies are vascular, including chronic venous insufficiency, peripheral arterial disease, and diabetic neuropathy. However, ulcers that are non-healing and refractory to standard treatment may reflect rarer underlying pathologies, warranting comprehensive reassessment. We report the case of an 87-year-old woman presenting with recurrent, painful, bilateral lower-limb ulcers, persisting for 18 months on the right leg and 10 months on the left. Her medical history was notable for chronic kidney disease, heart failure, and a previous myocardial infarction managed with dual coronary artery stenting. The ulcers had been treated in the community with dressings and multiple courses of oral antibiotics, with recurrent hospital admissions for secondary infection. She re-presented to the emergency department with worsening ulceration, rigours, raised inflammatory markers, and clinical features of infection. Initial management included intravenous antibiotics, analgesia, specialist wound care, and tissue viability input. Vascular surgical assessment confirmed adequate arterial supply, and there was no clinical evidence of peripheral neuropathy. Despite optimal conventional management, wound healing remained poor, prompting consideration of alternative diagnoses, including pyoderma gangrenosum, vasculitic ulceration, and cutaneous malignancy. Extensive autoimmune and vasculitis screening was negative. Punch biopsy demonstrated a vasculopathic pattern with increased vascular proliferation, fibrinoid necrosis of small vessels, diffuse neutrophilic infiltrates, and fibrin deposition extending into the deeper dermis. These findings were consistent with coexisting livedoid vasculopathy (LV) and acroangiodermatitis (AAD) secondary to chronic venous stasis, excluding other differentials. This combination is rare, particularly in advanced age. Treatment included topical clobetasol 0.05% cream to peri-wound skin, topical potassium permanganate 0.01% to infected areas, oral dapsone 50 mg twice daily for 3 months, and clopidogrel 75 mg daily, alongside compression therapy and multidisciplinary wound care. Marked clinical improvement was observed within two weeks. This case highlights the diagnostic complexity of chronic leg ulcers, the importance of maintaining a broad differential diagnosis, and the pivotal role of skin biopsy and multidisciplinary collaboration in guiding effective, individualised management.