What is the treatment for pediatric labial herpes (herpes labialis) flare?

From the Guidelines

For pediatric treatment of labial herpes flare, I recommend oral acyclovir as the first-line treatment at 15-30 mg/kg/day divided into 3-5 doses for 5-7 days (maximum 1200 mg/day) due to its efficacy in reducing the duration and severity of symptoms, as supported by studies examining the effectiveness of oral antiviral agents for management of recurrent herpes labialis outbreaks 1.

Treatment Options

• Oral acyclovir is the preferred treatment, with a dosage of 15-30 mg/kg/day divided into 3-5 doses for 5-7 days (maximum 1200 mg/day) 1.
• For children over 12 years, valacyclovir 2 grams twice daily for one day is an alternative, as it has been shown to be effective in treating herpes labialis in adults and older children 1.
• Topical treatments, such as 5% acyclovir cream applied 5 times daily for 4 days, or docosanol 10% cream applied 5 times daily until healing occurs, can also be used, especially for mild cases or in combination with oral antiviral therapy 1.

Supportive Care

• Supportive care is essential and includes acetaminophen or ibuprofen for pain relief, maintaining hydration, applying cold compresses to reduce discomfort, and using petroleum jelly to prevent cracking.
• Parents should be advised that the virus is contagious through direct contact until lesions are completely healed, so children should avoid sharing utensils, towels, or kissing others during outbreaks 1.

Timing of Treatment

• Treatment should begin at the first sign of symptoms (tingling, burning) for maximum effectiveness, as the natural healing process starts within the first 24 h of onset of an episode 1.
• For recurrent episodes, prophylactic therapy may be considered to reduce the frequency and severity of outbreaks.

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

• Pediatric treatment for labial herpes flare: For pediatric patients aged 12 years and older, the recommended dosage is 2 grams of valacyclovir twice daily for 1 day, taken 12 hours apart 2.
• For pediatric patients under 12 years, there is no established dosage for valacyclovir for the treatment of cold sores (herpes labialis) 2 2.
• An alternative option for pediatric patients 12 years and older is penciclovir cream, which is indicated for the treatment of recurrent herpes labialis (cold sores) in adults and children 12 years of age and older 3.

From the Research

Treatment Options for Pediatric Labial Herpes Flare

• Episodic treatment with oral antiviral agents, such as acyclovir, is effective in shortening the duration of pain and discomfort, hastening healing, and reducing viral shedding 4.
• Topical antiviral agents, such as 5% acyclovir cream/ointment, 1% penciclovir cream, can also be used for episodic treatment of herpes labialis 4.
• Chronic suppressive therapy with oral antiviral agents should be considered for patients with severe or frequent recurrences 4.
• Valacyclovir and famciclovir are not approved for children, but acyclovir can be used as an alternative 4.

Prevention of Herpes Labialis

• Prompt topical or oral therapy can alleviate symptoms of herpes labialis and contribute to its prevention 5.
• Oral antiviral medication can limit the number of relapses of herpes labialis in the long term 5.
• Sunscreens have shown mixed results in preventing herpes labialis, with some protection reported under experimental conditions, but not under natural conditions 5.

Pediatric Considerations

• Recurrent herpes labialis is a common condition in the pediatric population, with a point prevalence ranging from 0.72% to 5.2% 6.
• Pediatric herpes labialis can be associated with complications such as eczema herpeticum, erythema multiforme, reactive infectious mucositis eruptions, and hypersensitivity reactions 6.
• There are few studies that evaluate the rates of occurrence of these sequelae associated with pediatric herpes labialis 6.

Pharmacological Options

• Valacyclovir is a highly bioavailable prodrug of acyclovir, and is approved for the treatment of herpes simplex, herpes zoster, and other viral infections 7.
• Acyclovir is an alternative option for the treatment of herpes labialis in children, and can be used for episodic or chronic suppressive therapy 4, 7.