From the Guidelines
The best treatment for severe herpes stomatitis involves a combination of antiviral medications, pain management, and supportive care, with oral acyclovir being the primary treatment, typically prescribed at 400 mg five times daily for 7-10 days, as recommended by the most recent guidelines 1. The treatment approach should prioritize reducing morbidity, mortality, and improving quality of life.
- Antiviral medications are crucial in managing severe herpes stomatitis, with acyclovir being the first-line treatment, as it inhibits viral DNA replication, reducing the severity and duration of symptoms, and preventing secondary bacterial infections 1.
- For very severe cases, intravenous acyclovir at 5-10 mg/kg every 8 hours may be necessary, especially if the patient cannot take oral medications due to pain, as suggested by earlier guidelines 1.
- Alternative antivirals include valacyclovir (1000 mg twice daily) or famciclovir (250 mg three times daily), which offer better bioavailability and less frequent dosing, but their effectiveness in severe herpes stomatitis may be limited by resistance, as noted in the guidelines 1.
- Pain management is crucial and may include topical anesthetics like viscous lidocaine 2% (used as a mouthwash before meals), systemic analgesics such as acetaminophen or NSAIDs, and in severe cases, opioid medications, as recommended by expert opinion 1.
- Maintaining hydration and nutrition is essential, so soft, bland, non-acidic foods and cold liquids are recommended, and patients should avoid spicy, acidic, or rough-textured foods that can irritate the lesions, as suggested by preventive measures 1.
- Good oral hygiene should be maintained using a soft toothbrush and mild, non-irritating mouthwash, and patients should be advised to have regular dental examinations to assess the oral cavity and inform the healthcare professional at the first signs and symptoms of oral complications, as recommended by expert opinion 1.
From the Research
Treatment Options for Severe Herpes Stomatitis
- Acyclovir is a commonly used treatment for herpes simplex virus (HSV) infections, but resistance can occur, especially in immunocompromised patients 2, 3.
- Alternative treatments for acyclovir-resistant HSV infections include cidofovir and foscarnet, which can be used topically or intravenously 2, 3.
- Topical cidofovir and foscavir cream have been shown to be effective in treating acyclovir-resistant HSV-1 stomatitis in patients with severe disease 2.
- In cases of primary herpetic gingivostomatitis, acyclovir suspension has been shown to reduce the duration of symptoms and infectivity when started within the first three days of disease onset 4, 5.
Considerations for Treatment
- The choice of treatment should be based on the severity of the disease and the patient's immune status 2, 3.
- Early treatment is crucial in reducing the duration of symptoms and infectivity 4, 5.
- Topical treatments may be a less toxic alternative to intravenous therapy in some cases 2.
- The development of novel antiviral drugs and vaccines may help to address the issue of drug resistance in the future 3.