What is the appropriate treatment for herpangina in a child aged 3 months to 10 years?

Herpangina Treatment in Children

Herpangina is a self-limited viral illness requiring only supportive care—no antiviral or antibiotic therapy is indicated, and treatment focuses on symptom relief with oral analgesics, adequate hydration, and monitoring for complications. 1

Pathogen and Natural History

• Herpangina is caused by enteroviruses, most commonly Coxsackievirus A serotypes (A2, A4, A6, A10), with Enterovirus-A and Echovirus also implicated 1, 2, 3
• The illness is self-limiting with a typical course of 4–6 days and excellent prognosis 1
• Transmission occurs via fecal-oral route and respiratory droplets, with peak incidence in summer months (particularly July) 2, 4
• Most cases occur in preschool children, with over 80% affecting children ≤4 years of age 4

Clinical Diagnosis

• Diagnosis is based on characteristic pharyngeal lesions (small vesicles and ulcers on the soft palate, uvula, and tonsillar pillars), fever, and epidemiological context 1
• Virological testing (real-time RT-PCR of throat swabs) can confirm enterovirus but is not required for routine management 1, 2
• The characteristic oral lesions distinguish herpangina from other febrile illnesses and guide clinical decision-making 1

Supportive Treatment Protocol

Primary management consists of:

• Oral analgesics and antipyretics for pain and fever control (acetaminophen or ibuprofen at age-appropriate doses) 1
• Topical oral spray with benzydamine (0.255 mg/dose, 6 sprays 3 times daily as needed) for local pain relief 5
• Adequate hydration with emphasis on maintaining oral fluid intake despite painful oral lesions 1, 5
• Dietary modifications excluding salty, spicy, and fried foods that may irritate oral lesions 5
• Activity restriction during the acute febrile phase 5

What NOT to Do

• Do not prescribe antibiotics—herpangina is purely viral and antibacterial therapy provides no benefit 1
• Do not use systemic antiviral agents—no evidence supports their efficacy in enteroviral herpangina 1
• Do not perform routine virological testing in uncomplicated cases, as it does not alter management 1
• Avoid thermal procedures during the acute illness 5

Monitoring and Expected Course

• Expect complete resolution of symptoms within 4–6 days from onset 1
• Clinical improvement should be evident by day 3–4, with regression of oral lesions and defervescence 5
• Re-evaluate if fever persists beyond 5–7 days or if the child develops signs of dehydration, inability to maintain oral intake, or neurological symptoms 1

When to Escalate Care

Consider hospitalization or further evaluation if:

• The child cannot maintain adequate oral hydration due to severe odynophagia
• Signs of dehydration develop (decreased urine output, dry mucous membranes, lethargy)
• Neurological symptoms appear (altered mental status, severe headache, neck stiffness)—these may indicate enteroviral meningitis or encephalitis
• Fever persists beyond 5–7 days, suggesting possible secondary bacterial infection or alternative diagnosis

Adjunctive Immunomodulatory Therapy (Limited Evidence)

• Inosine pranobex (50 mg/kg/day divided into multiple doses for 7 days) has been reported in case series but lacks robust evidence for routine use 5
• This agent should be reserved for severe or complicated cases and is not part of standard first-line management 5

Key Clinical Pitfall

The most common error is prescribing antibiotics for herpangina based on pharyngeal erythema and fever—the characteristic vesicular/ulcerative lesions on the posterior pharynx distinguish this viral syndrome from bacterial pharyngitis, which presents with tonsillar exudate and anterior pharyngeal involvement 1. When in doubt, the self-limited 4–6 day course and lack of response to antibiotics confirm the viral etiology 1.