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.

Aetiology

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 transmited during childhood via direct contact
• The virus can be transmitted by salivary transfer by kissing or sharing utensils or towels (if there is contract with mucus membrane or open / abraded skin)

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

Investigation and Diagnosis

Both oral herpes and gingivostomatitis is a clinical diagnosis

• 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 Criteria

Consider admission if:

• 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

General Advice / Conservative Management

Reassure that oral herpes simplex infections are usually self-limiting and lesions should heal without scarring.

Symptom relief measurements:

• Paracetamol and/or ibuprofen – for fever and pain
• Adequate fluid intake

Advice to minimise risk of transmission:

• Avoid kissing an doral sex until all lesions have fully healed
• Do not share items that come into contact with lesions (e.g. makeup and lip balms)
• Avoid touching the lesions and wash hands immediately after touching lesions
• Take care if using contact lenses
• Defer elective dental treatment until all lesions have fully healed
• Inform parents or carers that children with herpes labialis or gingivostomatitis who are well do not need to be excluded from nursery or school

Anti-Viral Therapy

Consider oral antiviral (aciclovir / valaciclovir) in the ANY of the following:

• Primary infection in healthy people
• Immunocompromised people with primary or recurrent infection
• Recurrent infections, if lesions are severe / frequent / persistent

If an oral antiviral drug is indicated, advise the person to take the oral antiviral drug from the time of onset of prodromal symptoms before vesicles appear, if possible, until lesions have healed, for a minimum of 5 days.

References