Herpes stomatitis

Aim

To guide Emergency Department (ED) staff with the assessment and management of herpes stomatitis.

Background^1,2 

• Most primary infection by herpes simplex virus (HSV) type -1 in children is asymptomatic, or manifests as a mild upper respiratory infection.
• Approximately one quarter of primary infections manifest as gingivostomatitis, typically in the 1-5 year old age range but can occur in older children.
• HSV is highly contagious and is spread by direct contact with infected oral secretions and lesions.
• Following an incubation period of 2-12 days the child may develop gingivostomatitis, the severity of which ranges from mild discomfort to a debilitating illness requiring hospitalisation.
• Recovery usually occurs over 2 weeks. 

Complications¹

• Dehydration – main complication secondary to refusal to eat or drink because of pain. If pain can be controlled early this complication can often be avoided. However, hospitalisation is sometimes unavoidable by the time the child presents.
• Herpetic whitlow or herpetic keratitis (dendritic ulcer) – from auto-inoculation.
• Rare complications include herpes meningoencephalitis, and secondary bacterial infection of the lesions.
• Dermatitides – eczema herpeticum or erythema multiforme which may be debilitating if severe.
• Herpes infections in immuno-compromised patients can be very serious, and all cases should be discussed with a paediatrician. 

Clinical features^1,2

Herpes stomatitis

• Children typically present with fever, bad breath, and refusal to drink due to painful oral lesions involving the buccal and gingival mucosa.
• Half to two-thirds of patients also have extra-oral skin lesions around the mouth. These painful lesions begin as typical herpetiform vesicles, which may progress to pustules or erode to become ulcers. Untreated, the lesions may last for 12 days.
• Fever (< 39C) is common (especially if primary infection), and there may be enlarged cervical lymph nodes.

Diagnosis

• Diagnosis is clinical
• Though rarely needed, the diagnosis can be confirmed by viral scrapings, immunoflourescence of secretions or serology.

Differential diagnosis^1,2

• Coxsackie virus infections (hand-foot and mouth disease, herpangina)
• Aphthous ulcers
• Oral candidiasis
• Stevens-Johnson syndrome

Management^1,2

Analgesia

• Should be offered to all children with herpetic gingivostomatitis because of the degree of pain most suffer
• Early provision of adequate analgesia may prevent dehydration and the need for hospitalisation
  • Oral / rectal paracetamol (internal HealthPoint only)
  • Topical lidocaine (lignocaine) 2% oral liquid (Xylocaine viscous^®)³
    •  Directions³:
      • Swish the liquid around the mouth for 30 seconds, then spit it out; in children <3 years, apply to affected areas with a cotton swab. In pharyngeal anaesthesia, may be swallowed if child >12 years.
      • Do not eat or drink within 60 minutes of using lidocaine in the mouth or throat
    • Dose³:
      • < 3 years: up to 0.2 mL/kg (maximum 1.25 mL) every 3 hours if required; maximum of 4 doses daily.
      • 3–12 years: up to 0.2 mL/kg (maximum 5 mL) every 3 hours if required; maximum of 4 doses daily.
      • 12–18 years: up to 15 mL every 3 hours if required; maximum of 8 doses daily.

Aciclovir

• Refer to Aciclovir Monograph – Paediatric – ChAMP
• Refer to Guidelines for Drug Dosing in Overweight and Obese Children 2 to 18 Years of Age – Medication Management Manual
• Aciclovir administered within 72 hours of the first oral lesions appearing has been shown to shorten the duration of oral lesions, pain, fever and eating/drinking difficulties, and is thus recommended for all children with herpes gingivostomatitis presenting within 72 hours of the first oral lesions⁴:
  • Dose:
    • ≥ 4 weeks to 18 years:
      • Oral: 10 mg/kg/dose (to a maximum of 400 mg) five (5) times daily. Consider valaciclovir in children ≥3 months.
      • Duration: 7 days (or 5 days for episodic treatment).
  • If the patient is unable to swallow and requires IV Aciclovir refer to Aciclovir Monograph – Paediatric – ChAMP.
  • If the patient is immunocompromised please consult with their specialist as they usually need higher dose and longer treatment
  • Patients who present after 72 hours of first oral lesion with ongoing development of new lesions/and or severe pain should still be offered anti-viral therapy (discuss with ED consultant)
  • If in doubt discuss with ED consultants.

Adjunct treatment

• Chlorhexidine mouthwash 0.2% – hold 10mL in mouth for 1 minute 2-3 times a day while ulcers are present
• If younger children are unable to use a mouthwash, the alternative is chlorhexidine 0.5% dental oral gel. Substitute for toothpaste as an adjunct to oral hygiene.

Topical antiviral agents

• Topical antiviral agents are not helpful in the treatment of primary herpes gingivostomatitis in immunocompetent patients and are not recommended.

Antibiotics

• Antibiotics are not routinely used unless a secondary bacteria infection is diagnosed. 

Indication for admission¹

• Inability to maintain adequate hydration
• Immunocompromised host
• Eczema herpeticum
• Encephalitis, epiglotitis or pneumonitis (usually in immunocomprised patients) 

Nursing 

• Complete and record a full set of observations on the Observation and Response Tool and record additional information on the Clinical Comments chart.
• Minimum of hourly observations should be recorded whilst in the Emergency Department.
• Fluid input / output is to be monitored and documented.

References

1. Keels MA and Clements DA (2014) Herpetic gingivostomatitis in young children. UpTo Date. Accessed at www.uptodate.com
2. Aslanova M, Ali R, Zito PM. Herpetic Gingivostomatitis. [Updated 2023 Mar 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK526068/
3. AMH Children’s Dosing Companion (2022) Australian Medicines Handbook Pty Ltd 2022, [Internet] Lidocaine; [Modified July 2022, Cited 18 Oct 2022] Available from: Lidocaine - AMH Children's Dosing Companion (health.wa.gov.au)
4. Amir J, Harel L, Smetana Z, Varsano I. Treatment of herpes simplex gingivostomatitis with aciclovir in children: a randomised double blind placebo controlled study. BMJ. 1997 Jun 21;314(7097):1800-3
5. WA Health Child and Adolescent Health Service. Ear, Nose, Throat and Dental ChAMP Empiric Guidelines. June 2021

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