What are the treatment options for oral herpes?

Treatment Options for Oral Herpes

The treatment of choice for oral herpes (herpetic gingivostomatitis) is acyclovir 800 mg orally, five times daily for 7-10 days in adults, with treatment initiated within 72 hours of symptom onset, preferably within 24-48 hours for maximum benefit. 1

Antiviral Therapy Options

First-line Treatment

• Acyclovir: 800 mg orally, five times daily for 7-10 days 1
• Valacyclovir: 1000 mg orally, three times daily for 7 days 1
• Famciclovir: 500 mg orally, three times daily for 7 days 1

Special Populations

• Immunocompromised patients:

  • Higher acyclovir doses (400 mg five times daily) for 7-10 days 1
  • For severe cases: IV acyclovir 5-10 mg/kg every 8 hours until lesions heal 1
  • Note: Famciclovir is indicated for HIV-infected patients with recurrent episodes of orolabial herpes 2

• Pregnant patients:

  • Acyclovir 400 mg orally three times daily for 5-7 days OR
  • Acyclovir 200 mg orally five times daily for 5-7 days 1

Supportive Care Measures

Pain Management

• Acetaminophen or other analgesics based on pain severity 1
• Topical pain relief options:
  • Mixture of Maalox and diphenhydramine
  • Viscous lidocaine (use with caution in young children) 1

Hydration and Nutrition

• Encourage fluid intake to prevent dehydration
• Consider IV fluids if oral intake is severely compromised 1
• Recommend soft, non-acidic foods
• Cold foods/beverages may provide comfort 1

Skin Care

• Keep affected areas clean and dry to prevent secondary bacterial infection 1, 3

Treatment Monitoring and Follow-up

Expected Outcomes

• Improvement should be seen within 7-10 days of treatment initiation 1
• Early treatment significantly reduces:
  • Duration of oral lesions
  • Fever duration
  • Eating and drinking difficulties
  • Viral shedding period 1

When to Follow Up

Follow-up is necessary within 7-10 days if:

• Symptoms worsen
• No improvement after 72 hours of treatment
• New symptoms develop
• Patient is immunocompromised 1

Treatment Failure

If lesions don't begin to resolve within 7-10 days, consider:

• Treatment failure
• Possible resistance to antiviral medication 1, 4

Alternative treatments for resistant cases:

• Topical trifluridine
• Intravenous foscarnet (40mg/kg three times daily) 1, 4

Prevention Strategies

Trigger Avoidance

• UV radiation (use sunscreen SPF 15 or above) 1, 3
• Fever
• Psychological stress
• Local trauma 1

Suppressive Therapy

For frequent recurrences, consider:

• Acyclovir 400 mg 2-3 times daily 3
• Valacyclovir 500-2000 mg twice daily 3

Important Considerations and Pitfalls

• Timing is critical: Treatment should begin within 72 hours of symptom onset, preferably within 24-48 hours for maximum benefit 1
• Avoid topical corticosteroids: These can potentiate HSV infection 1
• Watch for complications: Evaluate for herpes zoster oticus (Ramsay Hunt syndrome) when ear pain is present 1
• Resistance concerns: Resistance to antiviral medications is rare in immunocompetent patients but more common in immunocompromised individuals 4
• Dosing matters: Higher doses (800 mg five times daily) of acyclovir are more effective than lower doses (400 mg five times daily) 5