1. Herpetic gingivostomatitis
1° infections with HSV (usually type 1, occasionally type 2) may be asymptomatic but
can cause a painful ulcerative gingivostomatitis (most often in children) that resolves in
10–14 days. Recurrent herpes labialis is caused by reactivation of the latent virus. A
tingling, burning, or itching prodrome is common. Erythema multiforme may be caused
by herpes infections and may recur.
What should I look for in 1° infections?
• Malaise, headache, and fever; cervical lymphadenopathy.
• Well-defined vesicles, 2mm in diameter, on the dorsum of the tongue and hard palate,
but vesicles may be scattered over the entire oral mucosa. Vesicles rupture rapidly to
form very painful shallow ulcers with a yellowish grey floor and erythematous margins.
• Inflamed gingival margins.
What should I do?
Management is symptomatic with fluids and pain relief. Oral aciclovir, 200mg x5/day for
5 days, is helpful in 1° attacks if vesicles are still present (within the first 3 days).
recurrent herpes labialis does not usually need treatment with aciclovir.
2. Genital herpes simplex virus infection
Genital infections are usually caused by HSV-2 and only occasion- ally by HSV-1. 1°
attacks are more severe and long-lasting than subsequent attacks. Prevalence is highest in
individuals adopting high-risk sexual behaviour, but viral carriage is often asymptomatic.
Genital HSV increases the risk of acquiring and/or transmitting HIV.
What should I look for?
• Genital pain, itching, and/or burning.
• Erythematous vesicles that rapidly rupture, forming painful ulcers.
• Dysuria leading to urinary retention.
What should I do?
• Consider other causes of ulcers, including EBV.
• Bacterial and viral culture—use a viral culture medium.
• Biopsy may be indicated if diagnosis is uncertain.
• Prescribe oral analgesia and topical 2% lidocaine gel.
• Encourage high fluid intake.
• Recommend warm baths (easier to urinate in a bath).
• Prescribe oral antivirals in 1° disease.
• Oral prophylaxis with antivirals in severe recurrent disease.
• Genital HSV infection can be transmitted to the fetus or neonate.
• Prophylactic aciclovir from 36 weeks of gestation reduces the risk of HSV recurrence or
HSV viral shedding at delivery.
• Refer for screening for other STDs.