What is the recommended treatment for herpes stomatitis?

Treatment of Herpes Stomatitis

For herpes stomatitis, the recommended first-line treatment is oral acyclovir 200 mg five times daily for 7-10 days, with valacyclovir 1 gram twice daily for 10 days as an effective alternative. 1, 2

Antiviral Therapy Options

First-line Treatment

• Acyclovir options:
  • 200 mg orally five times daily for 7-10 days 1
  • 400 mg orally three times daily for 5 days 1
  • 800 mg orally twice daily for 5 days 1

Alternative Treatment

• Valacyclovir options:
  • 1 gram twice daily for 10 days (for initial episodes) 2
  • 2 grams twice daily for 1 day (for herpes labialis/cold sores) 2

Severe Cases

• Intravenous therapy is indicated for severe cases:
  • Acyclovir 5-10 mg/kg body weight every 8 hours for 5-7 days until clinical resolution 1
  • Switch to oral therapy when improvement occurs 1

Supportive Care

Pain Management

• Topical pain relief:
  • Viscous lidocaine 2% mouthwash for pain control 3
  • Topical NSAIDs (e.g., amlexanox 5% oral paste) for moderate pain 3
  • Sodium bicarbonate containing mouthwash (non-alcoholic) every hour 3

Hydration and Nutrition

• Maintain adequate fluid and electrolyte balance 4
• Consider sugarless chewing gum or candy for oral dryness 3
• For severe pain interfering with eating, consider systemic analgesics following WHO pain management ladder 3

Management of Resistant Cases

If lesions do not begin to resolve within 7-10 days of starting therapy:

1. Suspect acyclovir-resistant HSV
2. Obtain viral culture and susceptibility testing
3. Consider alternative treatments:
   • Topical trifluridine (TFT) applied 3-4 times daily 5
   • Intravenous foscarnet 40 mg/kg three times daily or 60 mg/kg twice daily for 10 days 5

Special Considerations

Immunocompromised Patients

• Higher risk of severe disease and resistance to standard therapy 5, 6
• May require higher doses or longer duration of treatment
• Consider prophylactic therapy to prevent recurrences 1, 7
• Monitor closely for clinical response within 72 hours 1

Topical Corticosteroids for Severe Cases

• For persistent ulcers, consider topical high-potency corticosteroids:
  • Dexamethasone mouth rinse (0.1 mg/ml) for multiple or difficult-to-reach ulcerations 3
  • Clobetasol gel or ointment (0.05%) for limited, accessible ulcers 3

Patient Education

• Start treatment at earliest symptoms for maximum benefit 1, 2
• Complete the full course of medication even if symptoms improve
• Avoid sharing personal items that may contact the lesions
• Maintain good oral hygiene but avoid irritating products

Common Pitfalls to Avoid

1. Delaying treatment beyond 48 hours of symptom onset reduces efficacy 1, 2
2. Confusing herpes stomatitis with aphthous stomatitis (canker sores), which does not respond to acyclovir 8
3. Failing to adjust antiviral dosing in patients with renal impairment 1, 2
4. Overlooking HSV reactivation in immunocompromised patients on immunosuppressive medications 6

Early diagnosis and prompt initiation of antiviral therapy are crucial for reducing the duration and severity of herpes stomatitis, with treatment being most effective when started within 48 hours of symptom onset.