See also
Dehydration
Intravenous fluids
Acute pain management
Key points
- HSV gingivostomatitis is usually a self-limiting illness, which resolves without complications
- Management is focused on ensuring adequate hydration and analgesia
- Aciclovir should be administered to immunocompromised children
Background
- Primary herpes simplex virus (HSV) infection is usually asymptomatic. Herpetic gingivostomatitis is the most common clinical manifestation and occurs in 15-30% of cases
- Typical age is 6 months – 5 years, although can occur in older children and adolescents
- Neonatal HSV can be severe with significant morbidity and mortality; it is not covered in this guideline
- Reactivation can occur with cold, trauma, stress, or immunosuppression
- Hospitalisation is most often required due to dehydration
- Complications include herpetic whitlow (often in children who suck their thumb), herpetic keratitis, oesophagitis, pneumonitis, lip adhesions and secondary infections
Differential diagnoses
- Hand foot and mouth disease
- Herpangina
- Aphthous ulcers
- Stevens-Johnson Syndrome
- Behcet syndrome
- Reactive infectious mucocutaneous eruption (RIME)
Assessment
History
- Primary HSV infection occurs approximately one week after contact with a person shedding HSV (who is often asymptomatic)
- Usually begins with a prodrome which may include fever, anorexia, malaise and headache
- Oral vesicles may be very painful, resulting in refusal to drink
- Lesions heal in approximately 10-14 days (up to 3 weeks in severe cases)
- Lethargy, drowsiness or focal neurology and altered behaviour should raise concern for HSV
encephalitis
- Secondary infections are uncommon but should be considered if there is worsening of the child's symptoms (eg new onset of fever) after a period of gradual recovery
Examination
- Vesicles can be found on the buccal mucosa, tongue, gingiva, hard palate, pharynx, lips and perioral skin
- Lesions appear yellow after the vesicles rupture and develop a red halo. Vesicles bleed easily and can develop a black crust
- Assess hydration as dehydration is the most common complication
- Submandibular or cervical lymphadenitis may be present
- Examine for complications (neurological and eye examination)
See also
Dehydration
Intravenous fluids
Acute pain management
Key points
- HSV gingivostomatitis is usually a self-limiting illness, which resolves without complications
- Management is focused on ensuring adequate hydration and analgesia
- Aciclovir should be administered to immunocompromised children
Background
- Primary herpes simplex virus (HSV) infection is usually asymptomatic. Herpetic gingivostomatitis is the most common clinical manifestation and occurs in 15-30% of cases
- Typical age is 6 months – 5 years, although can occur in older children and adolescents
- Neonatal HSV can be severe with significant morbidity and mortality; it is not covered in this guideline
- Reactivation can occur with cold, trauma, stress, or immunosuppression
- Hospitalisation is most often required due to dehydration
- Complications include herpetic whitlow (often in children who suck their thumb), herpetic keratitis, oesophagitis, pneumonitis, lip adhesions and secondary infections
Differential diagnoses
- Hand foot and mouth disease
- Herpangina
- Aphthous ulcers
- Stevens-Johnson Syndrome
- Behcet syndrome
- Reactive infectious mucocutaneous eruption (RIME)
Assessment
History
- Primary HSV infection occurs approximately one week after contact with a person shedding HSV (who is often asymptomatic)
- Usually begins with a prodrome which may include fever, anorexia, malaise and headache
- Oral vesicles may be very painful, resulting in refusal to drink
- Lesions heal in approximately 10-14 days (up to 3 weeks in severe cases)
- Lethargy, drowsiness or focal neurology and altered behaviour should raise concern for HSV
encephalitis
- Secondary infections are uncommon but should be considered if there is worsening of the child's symptoms (eg new onset of fever) after a period of gradual recovery
Examination
- Vesicles can be found on the buccal mucosa, tongue, gingiva, hard palate, pharynx, lips and perioral skin
- Lesions appear yellow after the vesicles rupture and develop a red halo. Vesicles bleed easily and can develop a black crust
- Assess hydration as dehydration is the most common complication
- Submandibular or cervical lymphadenitis may be present
- Examine for complications (neurological and eye examination)
Management
Diagnosis is clinical and, in most cases, does not require laboratory confirmation
Investigations
- Where confirmation is required (immunocompromised host or contact), swab lesion (flocked swab) for PCR
- Serology is rarely helpful
Treatment
Care is mainly supportive (analgesia and hydration) although antiviral treatment should be considered in some children
| Analgesia |
Consider in all children with oral HSV
Pain relief options include
- Simple oral analgesia including paracetamol and ibuprofen
- While not shown to be efficacious, topical analgesics are commonly used eg Xylocaine Viscous®, Lignocaine gel 2%®, Mucosoothe® (in children
<3 years, apply to affected areas with a cotton swab)
- For severe pain, inpatient management and oral opiates may be required
|
| Hydration |
- Adequate fluid intake to avoid dehydration is essential
- Most children with mild or 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 over 1 hour can be considered - give small frequent volumes after analgesia
- Severe dehydration or failure of rehydration may necessitate NGT or IV rehydration
|
| Antiviral treatment |
- Treat immunocompromised children with aciclovir 10 mg/kg IV 8 hourly until there are no new lesions
- Immunocompetent children generally do not require antiviral treatment. However, if within 72 hr of onset of disease and in cases of severe pain or dehydration, consider aciclovir 10 mg/kg (max 400 mg) oral 5 times per day until there
are no new lesions
- Topical aciclovir is not effective
|
| Other |
- Children with gingivostomatitis, who do not have control of oral secretions, should be excluded from childcare/school until sores have dried
- Barrier cream (eg petroleum jelly) to the lips can prevent adhesions
|
Consider consultation with local paediatric team when
- Unable to maintain adequate hydration
- Immunocompromised
- Severe pain, keratitis, pneumonitis, eczema herpeticum, encephalitis
- IV aciclovir required
Consider transfer when
The child is requiring care above the level of comfort of the local services
For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services
Consider discharge when
The child is drinking adequate volumes to maintain hydration or follow up is arranged
Parent information sheet
Herpes simplex gingivostomatitis
Last updated November 2025
Reference List
- Amir J, et al. Clinical aspects and antiviral therapy in primary herpetic gingivostomatitis. Paediatr Drugs. 2001. 3 (8): 593–7.
- Amir J, et al. Treatment of herpes simplex gingivostomatitis with aciclovir in children: A randomised double blind placebo controlled study. Br Med J. 1997. 314 (7097): 1800–3.
- Coppola N, et al. Supportive care and antiviral treatments in primary herpetic gingivostomatitis: a systematic review. Clin Oral Inv. 2023. 17: 6333-6344. Retrieved from URL: https://link.springer.com/article/10.1007/s00784-023-05250-5
- Goldman RD. Acyclovir for herpetic gingivostomatitis in children. Can Fam Physician. 2016. 62 (5): 403–4.
- Hopper SM, et al. 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.
- Hudson B, et al. Does oral aciclovir improve clinical outcome in immunocompetent children with primary herpes simplex gingivostomatitis. Arch Dis Child. 2009. 94 (2): 165–7.
- Leflore S, et al. A risk-benefit evaluation of aciclovir for the treatment and prophylaxis of herpes simplex virus infections. Drug Saf. 2000. 23 (2): 131–42.
- Lewis M, et al. Oral ulceration: causes and management. Pharm J. 2019. 1–12. Retrieved from URL: https://www.pharmaceutical-journal.com/cpd-and-learning/learning-article/oral-ulceration-causes-and-management/20205786.article?firstPass=false
- Lin L, 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.
- Nikkels AF, et al. Treatment of mucocutaneous presentations of herpes simplex virus infections. Am J Clin Dermatol. 2002. 3 (7): 475–87.
- Porter SR. Little clinical benefit of early systemic aciclovir for treatment of primary herpetic stomatitis. Evid Based Dent. 2008. 9 (4): 117.
- Ramien ML. Reactive infectious mucocutaneous eruption: Mycoplasma pneumoniae-induced rash and mucositis and other parainfectious eruptions. Clin Exp Dermatl 2021; 46: 420-429
- Simmons S. Acute primary herpetic gingivostomatitis: a case report. DentistryIQ. 2019. Retrieved from URL: https://www.dentistryiq.com/clinical/pathology/article/16360031/acute-primary-herpetic-gingivostomatitis-a-case-report
- Zschocke I, et al. 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.
Management
Diagnosis is clinical and, in most cases, does not require laboratory confirmation
Investigations
- Where confirmation is required (immunocompromised host or contact), swab lesion (flocked swab) for PCR
- Serology is rarely helpful
Treatment
Care is mainly supportive (analgesia and hydration) although antiviral treatment should be considered in some children
| Analgesia |
Consider in all children with oral HSV
Pain relief options include
- Simple oral analgesia including paracetamol and ibuprofen
- While not shown to be efficacious, topical analgesics are commonly used eg Xylocaine Viscous®, Lignocaine gel 2%®, Mucosoothe® (in children
<3 years, apply to affected areas with a cotton swab)
- For severe pain, inpatient management and oral opiates may be required
|
| Hydration |
- Adequate fluid intake to avoid dehydration is essential
- Most children with mild or 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 over 1 hour can be considered - give small frequent volumes after analgesia
- Severe dehydration or failure of rehydration may necessitate NGT or IV rehydration
|
| Antiviral treatment |
- Treat immunocompromised children with aciclovir 10 mg/kg IV 8 hourly until there are no new lesions
- Immunocompetent children generally do not require antiviral treatment. However, if within 72 hr of onset of disease and in cases of severe pain or dehydration, consider aciclovir 10 mg/kg (max 400 mg) oral 5 times per day until there
are no new lesions
- Topical aciclovir is not effective
|
| Other |
- Children with gingivostomatitis, who do not have control of oral secretions, should be excluded from childcare/school until sores have dried
- Barrier cream (eg petroleum jelly) to the lips can prevent adhesions
|
Consider consultation with local paediatric team when
- Unable to maintain adequate hydration
- Immunocompromised
- Severe pain, keratitis, pneumonitis, eczema herpeticum, encephalitis
- IV aciclovir required
Consider transfer when
The child is requiring care above the level of comfort of the local services
For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services
Consider discharge when
The child is drinking adequate volumes to maintain hydration or follow up is arranged
Parent information sheet
Herpes simplex gingivostomatitis
Last updated November 2025
Reference List
- Amir J, et al. Clinical aspects and antiviral therapy in primary herpetic gingivostomatitis. Paediatr Drugs. 2001. 3 (8): 593–7.
- Amir J, et al. Treatment of herpes simplex gingivostomatitis with aciclovir in children: A randomised double blind placebo controlled study. Br Med J. 1997. 314 (7097): 1800–3.
- Coppola N, et al. Supportive care and antiviral treatments in primary herpetic gingivostomatitis: a systematic review. Clin Oral Inv. 2023. 17: 6333-6344. Retrieved from URL: https://link.springer.com/article/10.1007/s00784-023-05250-5
- Goldman RD. Acyclovir for herpetic gingivostomatitis in children. Can Fam Physician. 2016. 62 (5): 403–4.
- Hopper SM, et al. 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.
- Hudson B, et al. Does oral aciclovir improve clinical outcome in immunocompetent children with primary herpes simplex gingivostomatitis. Arch Dis Child. 2009. 94 (2): 165–7.
- Leflore S, et al. A risk-benefit evaluation of aciclovir for the treatment and prophylaxis of herpes simplex virus infections. Drug Saf. 2000. 23 (2): 131–42.
- Lewis M, et al. Oral ulceration: causes and management. Pharm J. 2019. 1–12. Retrieved from URL: https://www.pharmaceutical-journal.com/cpd-and-learning/learning-article/oral-ulceration-causes-and-management/20205786.article?firstPass=false
- Lin L, 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.
- Nikkels AF, et al. Treatment of mucocutaneous presentations of herpes simplex virus infections. Am J Clin Dermatol. 2002. 3 (7): 475–87.
- Porter SR. Little clinical benefit of early systemic aciclovir for treatment of primary herpetic stomatitis. Evid Based Dent. 2008. 9 (4): 117.
- Ramien ML. Reactive infectious mucocutaneous eruption: Mycoplasma pneumoniae-induced rash and mucositis and other parainfectious eruptions. Clin Exp Dermatl 2021; 46: 420-429
- Simmons S. Acute primary herpetic gingivostomatitis: a case report. DentistryIQ. 2019. Retrieved from URL: https://www.dentistryiq.com/clinical/pathology/article/16360031/acute-primary-herpetic-gingivostomatitis-a-case-report
- Zschocke I, et al. 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.