From the Guidelines
For pediatric patients with oral cold sores (herpes simplex labialis), the most effective treatment is acyclovir, which is the drug of choice for treatment of HSV among infants and children, regardless of HIV-infection status, as recommended by the CDC, the National Institutes of Health, and the Infectious Diseases Society of America 1.
Treatment Options
- For mild cases in children, supportive care is recommended, including acetaminophen or ibuprofen for pain relief and ensuring adequate hydration.
- Topical treatments like docosanol 10% cream (Abreva) can be used in children over 12 years, applied 5 times daily at the first sign of symptoms.
- For children over 6 years, cold sore patches or bandages may provide relief and prevent touching.
- In more severe cases, oral antiviral medications may be prescribed, such as acyclovir (20 mg/kg, 4-5 times daily for 5-7 days, maximum 1000 mg/day) for children over 2 years.
- Valacyclovir may be used in older children (20 mg/kg twice daily for 5 days, maximum 1000 mg/dose).
Important Considerations
- These medications work best when started within 72 hours of symptom onset.
- Parents should keep the area clean, avoid sharing utensils or towels, and prevent children from touching or picking at sores to prevent spreading the infection.
- Medical attention is necessary if the child has a compromised immune system, if sores don't heal within two weeks, or if there's high fever, difficulty eating or drinking, or spreading to the eyes.
Recent Guidelines
- The most recent study on the treatment of herpes labialis, published in 2024, recommends the use of oral antivirals such as acyclovir, valacyclovir, or famciclovir for the treatment of HSV conjunctivitis 2.
- Another study published in 2019 also recommends the use of oral antivirals for the treatment of HSV keratitis, and suggests that higher doses of oral antivirals may be effective in cases that appear to demonstrate resistance to therapy 3.
From the FDA Drug Label
The recommended dosage of VALTREX for the treatment of cold sores in pediatric patients aged greater than or equal to 12 years is 2 grams twice daily for 1 day taken 12 hours apart. Valacyclovir oral suspension (25 mg/mL or 50 mg/mL) may be prepared extemporaneously from 500-mg VALTREX tablets for use in pediatric patients for whom a solid dosage form is not appropriate
Treatment for Oral Cold Sore in Pediatric Patients:
- For pediatric patients aged greater than or equal to 12 years, the recommended dosage is 2 grams twice daily for 1 day taken 12 hours apart.
- For pediatric patients who cannot take solid dosage forms, valacyclovir oral suspension can be prepared from 500-mg tablets.
- The dosage for pediatric patients under 12 years is not established 4.
From the Research
Treatment Options for Oral Cold Sores in Pediatric Patients
- The treatment for oral cold sores, also known as herpes labialis, typically involves antiviral therapy to shorten the duration of pain and discomfort, hasten healing, and reduce viral shedding 5.
- For pediatric patients, the treatment options may be limited due to the lack of approval for certain antiviral agents in children.
- Topical antiviral agents such as 5% acyclovir cream/ointment (Zovirax) may be used for episodic treatment of herpes labialis in pediatric patients 5.
- Oral antiviral agents such as acyclovir (Zovirax) may be considered for pediatric patients, but the dosage and administration should be carefully evaluated due to the lack of approval for children 5, 6.
Antiviral Therapy for Herpes Labialis
- Antiviral therapy has been shown to be effective in reducing the duration and severity of herpes labialis episodes 6, 7, 8, 9.
- Oral antiviral agents such as valacyclovir (Valtrex) and famciclovir (Famvir) have greater oral bioavailability and are better absorbed than acyclovir, but are not approved for children 5, 8.
- Topical antiviral agents such as 1% penciclovir (Denavir) cream and 50 mg Buccal Adhesive Tablet (ABT-50 mg) may also be used for episodic treatment of herpes labialis, but are not effective in preventing recurrent episodes 5, 7.
Considerations for Pediatric Patients
- The safety and efficacy of antiviral agents in pediatric patients should be carefully evaluated due to the limited approval and studies in this population 6, 8.
- The treatment of herpes labialis in pediatric patients should be individualized and based on the severity and frequency of episodes, as well as the patient's overall health status 5, 7.