What is your approach to refractory oral ulcers in SLE?

I echo @Dr. First Last thoughts! Failure of HCQ does not mean refractory disease. Oral ulcers in SLE often correlate with underlying disease activity and their presence signals a better need for disease control. I would consider escalation to a systemic DMARD, such as MMF, MTX, anifrolumab, or belim...

Would not consider only trying HCQ as being refractory. Many more lupus medications to be tried! Azathioprine, MMF, Methotrexate, and Benlysta would all be under consideration. I presume their labs show some aspect of active SLE.

In real life, oral ulcers are sometimes unrelated to lupus. I advise patients to try SLS‑free toothpaste; and some do report good benefit from it.

Sodium Lauryl Sulphate (SLS) is a foaming agent added to toothpaste and it is an irritant to many people, causing oral sores.

Prior to availability of apremilast for psoriatic disease and Behcet disease (which can be effective if a case can be made for the patient accessing this), I found thalidomide to be very effective for this.