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Clinical Practice Guidelines

HSV Gingivostomatitis

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    PIC Endorsed

    • See also

      Dehydration
      Intravenous fluids
      Acute pain management

      Key points

      1. HSV gingivostomatitis is usually a self-limiting illness, which resolves without complications
      2. Management is focused on ensuring adequate hydration and analgesia
      3. 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)
      HSV Gingivostomatitis image 1
      HSV Gingivostomatitis image 2
      HSV Gingivostomatitis image 3

      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

      1. 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.