Presented by Fahad Malik, MD
Should PO acyclovir be used to treat primary HSV gingivostomatitis in immunocompetent patients?
- What dose?
- For how long?
Primary HSV Gingivostomatitis
- Prodrome – fever, anorexia, malaise, sleeplessness, etc.
- Red, edematous gingiva and clusters of small vesicles
- Vesicle rupture & become surrounded by a red halo
- Coalesce to form large, painful ulcers
- Involve: buccal mucosa, tongue, gingiva, hard palate, and pharynx
- Lips and perioral skin involved in 2/3 of cases
- Refusal to eat/drink, dehydration
- Most common between 6mo and 5y
- No seasonal distribution
- Rates of diagnosis (retrospective review from 1999-2003 in NY)
- 1.6 per 10,000 ED visits
- 5.6 per 10,000 admissions
- Direct contact with infected oral secretions or lesions
- Viral shedding for 1wk to several wks (median = 3 wks)
- Incubation period: 2d – 2wks (mean = 4d)
Amir 1997: Conclusions
- Acyclovir x 7 days significantly more effective than placebo*
- Duration of lesions (4.0 to 8.0)
- Duration of fever (0.8 to 3.2)
- Eating difficulties (1.31 – 4.69)
- Drinking difficulties (1.1 to 4.9)
- Viral shedding (2.9 to 5.1)
- *Dosing of acyclovir:
- 15mg/kg, five times daily x 7 days
*(difference in medians in days, 95% CI)
Cochrane Review: Discussion
“Implications for practice”
- Some “weak evidence” that acyclovir is an effective treatment
- Reduces # of oral lesions
- Prevents development of new lesions
- Decreases PO difficulties
- Only applicable to children < 6y
“Implications for research”
- Need larger samples
- Reduce systematic bias by blinding evaluators of outcomes
- Standardize evaluators
- Include patient-reported outcomes (quality of life, satisfaction)
Faden 2006: Conclusions
- Acyclovir was rarely used despite multiple studies reporting shortened course of illness
- Most commonly used therapies:
- Supportive care with IVF
- Pain management
- Topical agents:
- Diphenhydramine + Maalox
- Viscous lidocaine
- Swish and spit not possible for younger children
- Ingested lidocaine can have rare but serious side effects
Should PO acyclovir be used to treat 10 HSV gingivostomatitis in immunocompetent patients?
- If <72hrs of oral lesions – significantly shortens the duration of illness
- May shorten hospital course, prevent hospitalization, ↓ cost
- Need additional studies with larger sample size
- Significance only shown if oral lesions for <72 hrs
- Negative effects of PO acyclovir:
- Side effects: HA, malaise, N/V, diarrhea
- Development of resistant strains
- Seen in immunocompromised patients that received multiple courses
- What dose?
- For how long?
When: ideally within 72 hours of oral lesions, to reduce duration of illness
Dosing (further studies needed)
- Current practice: 40-80 mg/kg/day q6-q8hrs x 7 days
- Harriett Lane: 12o0mg/day divided q8hrs x 7-10 days
- Immunocompromised dosing (Lexicomp):
- 1000 mg/day in 3-5 divided doses x 7-14 days; maximum daily dose should not exceed 80 mg/kg/day (Red Book, 2009; Red Book, 2012)
Amir J, Harel L, Smetana Z, Varsano I. Treatment of herpes simplex gingivostomatitis with aciclovir in children: a randomised double blind placebo controlled study. BMJ. 1997 Jun 21;314(7097):1800-3.
Nasser M, Fedorowicz Z, Khoshnevisan MH, Shahiri Tabarestani M. Acyclovir for treating primary herpetic gingivostomatitis. Cochrane Database Syst Rev. 2008 Oct 8;(4):CD006700.
Faden H. Management of primary herpetic gingivostomatitis in young children. Pediatr Emerg Care. 2006 Apr;22(4):268-9.
Harriet Lane Handbook, 8th edition.