HSV Gingivostomatitis

  • See also       

    Intravenous fluids
    Acute pain management

    Key points

    1. HSV Gingivostomatitis is usually a self-limiting illness, which resolves without complications
    2. The mainstay of treatment is ensuring adequate hydration and analgesia
    3. Aciclovir should be administered in children who are immunocompromised


    • Primary Herpes simplex virus (HSV) infection in children is usually asymptomatic or non-specific. Herpetic gingivostomatitis is the most common specific clinical manifestation, occurring in 15-30% of cases
    • Reactivation can occur with cold, trauma, stress, or immunosuppression
    • Complications include: eczema herpeticum, herpetic whitlow (often in children who suck their thumb), lip adhesions and secondary infections



    • Illness occurs approximately one week after contact with an infected person (the contact case often is asymptomatic)
    • Generally, begins with a prodrome which may include fever, anorexia, malaise, sleeplessness and headache
    • The lesions heal in approximately 10-14 days (up to 3 weeks in severe cases)
    • Refusal to drink may result in dehydration, which is the most common complication
    • Lethargy, drowsiness or focal neurology and altered behaviour may indicate HSV encephalitis
    • Rarer complications are oesophagitis, epiglottitis, pneumonitis and keratitis


    • Lesions involve the buccal mucosa, tongue, gingiva, hard palate, pharynx, lips and perioral skin
    • Rash is vesicular and can easily bleed. The vesicles appear yellow after rupture and develop a red halo, while bleeding vesicles can develop a black crust.
    • Submandibular or cervical lymphadenitis may be present
    • Examine for complications (neurological & eye examination) 
    HSV Gingivostomatitis image 1  HSV Gingivostomatitis image 2  HSV Gingivostomatitis image 3 

    Assess hydration

    See dehydration

    Differential Diagnosis

    • Hand foot and mouth disease
    • Facial eczema herpeticum 
    • Aphthous ulcers
    • Stevens-Johnson Syndrome
    • Behcet syndrome


    Diagnosis is clinical and, in most cases, does not require laboratory confirmation


    • Where confirmation is required (immunocompromised host or contact), swab lesion (flocked swab) for PCR
    • Serology is rarely helpful


    Care is mainly supportive (analgesia and hydration)

    Pain relief options include;

    • Simple oral analgesia including paracetamol and ibuprofen
    • Topical analgesics eg Xylocaine Viscous® or Lignocaine gel 2%®
    • For severe pain, inpatient management and oral opiates may be required

    Adequate fluid intake to avoid dehydration is essential

    • Most children with mild/no dehydration can be discharged without a trial of fluids after appropriate advice and scheduled review
    • For moderate dehydration, a trial of oral rehydration solution (ORS) 10-20 mL/kg fluid over 1 hour can be considered - give small frequent volumes after analgesia.
    • Severe dehydration or failure of rehydration may necessitate nasogastric tube or IV management.

    Antiviral Treatment

    • Treat immunocompromised children with Aciclovir 10 mg/kg (max 400 mg) IV 8 hourly until there are no new lesions
    • Topical aciclovir is not effective
    • Immunocompetent children generally don’t require antivirals.  However, if within 72 hr of onset of disease and in cases of severe pain, dehydration, consider Aciclovir 10 mg/kg (max 400 mg) PO 5 times per day until there are no new lesions 

    Other Considerations

    • Children with gingivostomatitis who do not have control of oral secretions should be excluded from child care/school
    • Barrier cream (eg petroleum jelly) to the lips to prevent adhesions

    Consider consultation with local paediatric team when

    Child requires admission to hospital:

    • Inability to maintain adequate hydration
    • Immunocompromised children as require IV Aciclovir
    • Complication of infection such as severe pain, keratitis, encephalitis pneumonitis, eczema herpeticum

    All other children can be discharged home with GP follow up if required

    Consider transfer when

    The child is requiring care above the level of comfort of the local provider

    For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.

    Consider discharge when

    When the child is drinking adequate volumes to maintain hydration or follow up is arranged

    Parent information sheet

    Herpes Simplex Gingivostomatitis

    Last Updated February 2020

  • Reference List

    1. Amir J. Clinical aspects and antiviral therapy in primary herpetic gingivostomatitis. Paediatr Drugs. 2001;3(8):593–7.
    2. Amir J, Harel L, Smetana Z, Varsano I. Treatment of herpes simplex gingivostomatitis with aciclovir in children: A randomised double blind placebo controlled study. Br Med J. 1997;314(7097):1800–3.
    3. Goldman RD. Acyclovir for herpetic gingivostomatitis in children. Can Fam Physician. 2016;62(5):403–4.
    4. Hopper SM, McCarthy M, Tancharoen C, Lee KJ, Davidson A, Babl FE. Topical lidocaine to improve oral intake in children with painful infectious mouth ulcers: A blinded, randomized, placebo-controlled trial. Ann Emerg Med. 2014;63(3):292–9.
    5. Hudson B, Powell C. Does oral aciclovir improve clinical outcome in immunocompetent children with primary herpes simplex gingivostomatitis. Arch Dis Child. 2009;94(2):165–7.
    6. Keels MA, Clements DA. Herpetic gingivostomatitis in children. [Internet]. Up to Date. 2019. Available from: https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-behcet-syndrome?search=hsv gingivostomatitis&topicRef=6046&source=see_link
    7. Leflore S, Anderson PL, Fletcher C V. A risk-benefit evaluation of aciclovir for the treatment and prophylaxis of herpes simplex virus infections. Drug Saf. 2000;23(2):131–42.
    8. Lewis M, Wilson N. Oral ulceration: causes and management. Pharm J [Internet]. 2019;1–12. Available from: https://www.pharmaceutical-journal.com/cpd-and-learning/learning-article/oral-ulceration-causes-and-management/20205786.article?firstPass=false
    9. Lin L, Chen X, Cui P, Wang J, Guo Z, Lu N, et al. Topical application of penciclovir cream for the treatment of herpes simplex facialis/labialis: A randomized, double-blind, multicentre, aciclovir-controlled trial. J Dermatolog Treat. 2002;13(2):67–72.
    10. Nikkels AF, Pièrard GE. Treatment of mucocutaneous presentations of herpes simplex virus infections. Am J Clin Dermatol. 2002;3(7):475–87.
    11. Porter SR. Little clinical benefit of early systemic aciclovir for treatment of primary herpetic stomatitis. Evid Based Dent. 2008;9(4):117.
    12. Simmons S. Acute primary herpetic gingivostomatitis: a case report [Internet]. DentistryIQ. 2019. Available from: https://www.dentistryiq.com/clinical/pathology/article/16360031/acute-primary-herpetic-gingivostomatitis-a-case-report
    13. Sobolewski B. Gingivostomatits [Internet]. Pediatric Emergency Medicine Blog. 2019. Available from: https://pemcincinnati.com/blog/briefs-gingivostomatits/
    14. Zschocke I, Reich C, Zielke A, Reitmeier N, Reich K. Silica gel is as effective as acyclovir cream in patients with recurrent herpes labialis: Results of a randomized, open-label trial. J Dermatolog Treat. 2008;19(3):176–81.