Management of Herpetic Gingivostomatitis in Children
For mild to moderate herpetic gingivostomatitis in children, treat with oral acyclovir 20 mg/kg per dose (maximum 400 mg/dose) three times daily for 5-10 days, initiated within the first 3 days of symptom onset. 1
Disease Severity Assessment and Treatment Algorithm
Mild Symptomatic Gingivostomatitis
- Oral acyclovir 20 mg/kg per dose (maximum 400 mg/dose) three times daily for 5-10 days 1
- Treatment must begin within 72 hours of disease onset to achieve meaningful clinical benefit 2, 3
- Continue therapy until lesions completely heal 1
- Monitor for clinical improvement within 48-72 hours 4
Moderate to Severe Symptomatic Gingivostomatitis
- Start with IV acyclovir 5-10 mg/kg per dose three times daily 1
- After lesions begin to regress, transition to oral acyclovir and continue until complete healing 1
- These children often require hospitalization for IV hydration and pain management 5
Critical Timing Consideration
The therapeutic window is narrow—antiviral therapy only provides significant benefit when started within the first 3 days of disease onset. 2, 3 Peak viral replication occurs in the first 24 hours after lesion onset, making early treatment imperative 1. Three randomized, double-blind, placebo-controlled trials demonstrated that early acyclovir treatment significantly shortens the duration of all clinical manifestations and reduces infectivity compared to placebo 2, 3.
Supportive Care Measures
- Adequate analgesia and antipyretics for pain and fever control 6, 5
- Ensure adequate hydration—parenteral rehydration may be necessary if oral intake is severely compromised 6, 5
- Monitor renal function during acyclovir therapy and ensure adequate hydration to prevent nephrotoxicity 4
Special Populations and Resistant Cases
Acyclovir-Resistant HSV Infection
- Foscarnet 40 mg/kg per dose IV three times daily 1, 4
- Alternative dosing: 60 mg/kg per dose IV twice daily 1
Neonates with HSV Infection
- Higher doses required: IV acyclovir 20 mg/kg every 8 hours for 14 days (skin/eye/mouth disease) or 21 days (CNS disease) 1, 4
- For neonatal CNS disease, repeat CSF HSV DNA PCR at days 19-21 and do not stop acyclovir until negative 1
Immunocompromised Children (HIV-infected)
- Same dosing as immunocompetent children for mild disease 1
- Lower threshold for IV therapy given risk of more severe and prolonged disease 1
Common Pitfalls to Avoid
Topical therapies are largely ineffective. While topical antivirals, Maalox/diphenhydramine mixtures, and viscous lidocaine are frequently used (73% and 15% respectively in one study), they provide minimal clinical benefit 7. Topical antivirals do not reach the site of viral reactivation and cannot impact the host immune response 1. One study found acyclovir was only used in 17% of cases when it should have been the primary treatment 7.
Do not delay treatment waiting for laboratory confirmation. Diagnosis is clinical based on characteristic vesicular eruptions on the buccal and gingival mucosa and tongue 6, 5. Laboratory confirmation is only needed in immunocompromised patients with atypical presentations 1.
The disease is self-limiting but causes significant morbidity. Without treatment, symptoms persist for 10-14 days with substantial pain, dysphagia, and inability to eat or drink during the first week 6, 5. This leads to considerable healthcare costs and parental work disruption 6.