Definition
Oral herpes (also known as cold sores or herpes labialis) is a herpes simplex virus infection of the oral and perioral region.
Gingivostomatitis: herpes simplex virus infection of the oropharyngeal mucosa.
Causes and Risk Factors
Herpes simplex virus (HSV) is a double-stranded DNA virus
Types of HSV:
- HSV-1 – causes >90% cases of oral herpes
- HSV-2 – rarely causes oral herpes, typically in association with orogenital sex
Transmission:
- HSV-1 is usually transmitted during childhood via direct contact
- The virus can be transmitted by salivary transfer by kissing or sharing utensils or towels (if there is contact with mucous membrane or open / abraded skin)
Possible triggers:
- Exposure to UV light (esp. prolonged exposure)
- Extreme temperatures
- Stress (physical or emotional)
- Fever
- Fatigue
- Immunosuppression
- Local trauma
- Dental / surgical procedures
Clinical Features
Oral Herpes
Typical presentation:
- Prodrome of pain / burning / tingling / itching / paraesthesia (typically lasts for 6-48 hours)
- Crops of vesicles → rupture → superficial ulcers
- Most common location: mucocutaneous junction of the lower lip
- The ulcers crust over and heal, usually without scarring
Gingivostomatitis
Typical presentation:
- Prodrome of fever / malaise / sore throat / lymphadenopathy
- Sore throat / mouth with excess salivation and drooling (esp. in children)
- Crops of painful vesicles on a red swollen base that often form ulcers on the oral and pharyngeal mucosa
Complications
Acute complications:
- Dehydration (from poor oral intake due to painful swallowing)
- Direct extension of oropharyngeal infection can cause
- Pneumonia
- Oesophagitis
- Eczema herpeticum (in those with atopic eczema)
- Rare but serious complications include aseptic meningitis, encephalitis, myelitis, hepatitis
Complications from autoinoculation:
- Herpetic whitlow (lesions on the hands or digits)
- Eye disease (e.g. herpes keratoconjunctivitis, herpes keratitis) – esp. in contact lens users
- Herpes sycosis of the beard area (from shaving)
- Herpes gladiatorum (lesions on the torso or anywhere that has skin-to-skin contact) – typically seen in those who play contact sports (e.g. rugby, wrestling)
Recurrent herpes can cause erythema multiforme (a hypersensitive reaction)
Investigation and Diagnosis
Both oral herpes and gingivostomatitis are clinical diagnoses
- Investigations are not routinely needed in primary care
- Only consider investigating for underlying immunosuppression if there are unexplained recurrent infections that are severe or persistent
Management
Admission and Referral Criteria
Consider admission to hospital if ANY of the following:
- Unable to swallow due to pain + at risk of dehydration (esp. in children)
- Immunocompromised with severe oral herpes simplex infection
- Serious complication that requires IV antiviral treatment
Consider referring or seeking specialist advice if any of the following:
- Immunocompromised with troublesome recurrent infections (prophylactic oral antiviral treatment may be needed)
- Pregnant woman (esp. near term due to the risk of neonatal transmission)
- Frequent (e.g. 6 or more episodes in 1 year), persistent, and/or severe episodes (prophylactic oral antiviral treatment may be needed)
- Associated with recurrent erythema multiforme
- Lesions refractory to oral antiviral treatment (if indicated) after 5-7 days
- Diagnostic uncertainty
Conservative / General Management
Reassure that oral herpes simplex infections are usually self-limiting and lesions should heal without scarring.
| Self-care advise |
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| Topical preparations | NICE CKS: do NOT prescribe topical anaesthetic / topical analgesia / mouthwash / lip barrier preparations
However, NICE CKS noted that these products are available over-the-counter, and may be used if the patient finds them helpful |
| Advice to minimise the risk of transmission |
Children with herpes labialis or gingivostomatitis who are otherwise well do not need to be excluded from nursery or school |
Anti-Viral Therapy
| Oral antiviral treatment (aciclovir / valaciclovir) | Consider oral antiviral in ANY of the following scenarios:
If an oral antiviral drug is indicated, it should be taken from the onset of prodromal symptoms before vesicles appear, until lesions have healed, for a minimum of 5 days. Do not routinely prescribe oral antiviral drug treatment for otherwise well and healthy patients. The evidence on the benefits of oral antivirals is limited, and oral treatment needs to be initiated at the onset of prodromal symptoms, which may be difficult for people in practice. |
| Topical antiviral preparation (e.g. aciclovir, penciclovir) | NICE CKS: do NOT routinely prescribe topical antiviral preparations
However, NICE CKS noted that these products are available over-the-counter, and may be used if the patient finds them helpful. If being used, start from the onset of prodromal symptoms before vesicles appear and until lesions have healed. |