What is the recommended treatment for facial herpes simplex infection in a healthy 12‑year‑old child?

Treatment of Facial Herpes Simplex in a 12-Year-Old

For a healthy 12-year-old with facial herpes simplex infection, oral acyclovir 20 mg/kg (maximum 400 mg) three times daily for 5-10 days is the recommended treatment, with intravenous acyclovir 5-10 mg/kg every 8 hours reserved for moderate to severe cases. 1

Treatment Algorithm Based on Disease Severity

Mild Symptomatic Facial HSV (e.g., mild gingivostomatitis)

• Oral acyclovir 20 mg/kg per dose (maximum 400 mg/dose) three times daily for 5-10 days 1
• This dosing applies to children under 45 kg 1
• Treatment should be initiated as early as possible following onset of signs and symptoms 2

Moderate to Severe Symptomatic Disease

• Start with intravenous acyclovir 5-10 mg/kg per dose every 8 hours 1
• Once lesions begin to regress, transition to oral acyclovir and continue until lesions completely heal 1
• For children under 12 years with mucosal and cutaneous HSV in immunocompromised states, the dose is 10 mg/kg infused over 1 hour every 8 hours for 7 days 2

Critical Management Principles

Absolute Contraindications

• Topical corticosteroids are absolutely contraindicated in HSV infection, as they potentiate viral replication and worsen the infection 1
• This is a critical pitfall to avoid, as corticosteroids can lead to severe disease progression 3

Ocular Involvement Considerations

If there is any suspicion of eye involvement (conjunctivitis, keratitis):

• Combination therapy with both topical antiviral (ganciclovir 0.15% gel three to five times daily OR trifluridine 1% solution five to eight times daily) AND oral antiviral is mandatory 1
• Oral antivirals alone are insufficient to prevent progression of HSV blepharoconjunctivitis 1
• Topical ganciclovir is less toxic to the ocular surface than trifluridine, which inevitably causes epithelial toxicity if used for more than 2 weeks 1

Follow-Up Requirements

• Re-evaluate within 1 week with visual acuity measurement (if ocular involvement) and assessment of lesion healing 1
• Continue treatment until lesions completely heal 1

Alternative Oral Antiviral Options

While acyclovir is the standard treatment in pediatrics, other options exist:

• Valacyclovir and famciclovir are approved for adults and adolescents but have limited pediatric data and no pediatric preparation 1
• These could potentially be used by older children (≥12 years) able to receive adult dosing 1
• Valacyclovir dosing in adults is 500 mg two or three times per day 1

Special Considerations for Acyclovir-Resistant Cases

If the patient fails to respond to standard acyclovir therapy after 5-7 days:

• Intravenous foscarnet 40 mg/kg three times daily or 60 mg/kg twice daily should be used 1, 4
• Acyclovir resistance is rare in immunocompetent patients but should be considered if there is no clinical improvement 4
• Repeat cultures and susceptibility testing should be obtained if resistance is suspected 4

Common Pitfalls to Avoid

• Do not use topical antivirals alone for facial HSV - they are insufficient without systemic therapy 1
• Do not delay treatment - efficacy is greatest when initiated early in the disease course 2, 5
• Do not use intramuscular or subcutaneous injection of acyclovir - only intravenous or oral routes are appropriate 2
• Do not use rapid or bolus intravenous injection - acyclovir must be infused over 1 hour to prevent renal toxicity 2