Oral Herpes

Background

• Herpes labialis is a contagious viral infection primarily with herpes simplex virus type 1 (HSV-1), and less often with herpes simplex virus type 2 (HSV-2), resulting in a rash of the skin and mucous membranes (usually lips).
• Primary outbreaks manifest as herpetic gingivostomatitis, while recurrent episodes usually affect the vermillion border of lips or the mucosa of the hard palate.
• HSV-1 can be transmitted via mucous membranes/secretions and open or abraded skin by kissing and by sharing utensils or towels.
• Symptoms will resolve but the infection cannot be cured due to the lifelong latency of the virus.

Evaluation

• The primary oral infection can be asymptomatic or cause self-limiting herpetic gingivostomatitis characterized by vesicular lesions of any part of the oral mucosa, including the lips, gingiva, oral palate, or tongue..
• Recurrent episode lesions frequently have a prodrome of tingling, itching, and burning, and appear as clusters of vesicles on the lip or vermilion border.

Management

• Treatment may not be needed or used by many patients due to the self-limited nature of the episode.
• Consider antiviral medications for immunocompromised patients and consider offering treatment to healthy persons with frequent or severe outbreaks.
• Antiviral dosing options to treat recurrent episodes in adults and adolescents include:
  • acyclovir
    • 400 mg orally 5 times daily for 5 days
    • alternative oral dosing commonly used in clinical practice includes:
      • 200 mg orally 5 times daily for 5 days
      • 400 mg orally 3 times daily for 5 days
      • 800 mg orally twice daily for 5 days
      • 800 mg orally 3 times daily for 2 days
    • 50 mg buccal tablet applied once at onset of prodromal symptoms
  • valacyclovir 2 g orally every 12 hours for 1 day (2 doses)
  • famciclovir
    • 1,500 mg orally as a single dose
    • 750 mg orally every 12 hours for 1 day (2 doses) (alternative off-label dosing used in clinical practice)
• Antiviral dosing to treat acute primary infection in children includes:
  • acyclovir 15 mg/kg (up to 200 mg) orally 5 times daily for 7 days
  • valacyclovir 1 g orally twice daily for 7 days (in children ≥ 12 years old)
  • famciclovir 500 mg orally twice daily for 7 days (in children ≥ 12 years old)
• Topical intermittent episodic therapy (starting at earliest sign or symptom), such as with acyclovir 5% cream, combination 5% acyclovir plus 1% hydrocortisone cream, penciclovir 1% cream, or docosanol 10% cream, is an alternative to systemic antiviral medications.
• For chronic suppressive therapy (secondary prophylaxis) consider:
  • acyclovir 400 mg orally 2-4 times daily.
  • valacyclovir 500-1,000 mg orally once daily or 500 mg orally twice daily
  • famciclovir 250-500 mg orally twice daily