HSV

• Herpes simplex oral type 1 and 2:

  • Oral HSV usually causes a mild, self-limiting infection of the lips, cheeks, nose or oropharyngeal mucosa
  • HSV type 1 is the most common cause (>90% of cases)
  • Rarely HSV type 2 can cause oral infection - typically associated with orogenital sex
• Primary infection:

  • Transmission usually happens in childhood - contact with infected secretions from a person actively shedding the virus
  • HSV lesions are most contagious at time of vesicular rupture and continue to be contagious until they have scabbed - some people can be shedding HSV virus with no clinical lesion present
  • Most primary HSV infections are asymptomatic. If symptomatic children can develop gingivostomatitis, or pharyngitis in young adults
  • Following primary infection HSV 1 migrates to local sensory ganglia (usually trigeminal nerve) where it can remain latent or can reactivate
• Recurrent infection:

  • 40% of those who've had primary infection will have recurrent oral herpes simplex infections
  • Recurrence typically occurs 2-3 times a year but can be more
  • 90% of recurrent infections present as herpes labialis - cold sores
  • In immunocompromised people it can cause recurrent gingivostomatitis
• Herpes labalis presentation:

  • Prodrome of pain, burning, tingling, itching, paraesthesia
  • Followed 6-48 hours later by crops of vesicles that rupture leaving superficial ulcers that crust over - heal usually without scarring
  • Typically occur at mucocutaneous junction of the lips and most commonly on the lower lip
  • Usually mild and self limiting and resolves within 10-14 days
• Gingivostomatitis presentation:

  • Prodrome of fever, malaise, sore throat, cervical and submandibular lymphadenopathy
  • Followed by crops of painful vesicles that often rupture forming ulcers on pharyngeal and oral mucosa
  • Usually resolves in 2-3 weeks
• Triggers for reactivation of virus:

  • Prolonged exposure to UV light
  • Physical or emotional stress
  • Extremes in temperature
  • Menstruation
  • Immunosuppression
  • Mouth or lip trauma to the area of primary infection
  • Dental or surgical procedures
• Diagnosis:

  • Clinical diagnosis
  • Investigations not typically needed unless someone has unexplained severe recurrent infections - investigate for underlying immunosuppression e.g. HIV
• Complications:

  • Dehydration if poor oral intake due to painful swallowing
  • Autoinnoculation of other areas=

  1. Herpetic whitlow - vesicular lesions on hands or digits
  2. Eye disease - corneal ulceration, herpetic keratoconjunctivitis
  3. Follicular infection in beard area due to shaving

  • Eczema herpeticum - extensive eruptions of herpes simplex in people with atopic eczema often on face and neck
  • Erythema multiforme - hypersensitivity reaction triggered by HSV - target lesions
• Rare but serious complications:

  • More likely in immunocompromised patients, spread of infection to:
  • Airways - pneumonia
  • CNS - aseptic meningitis, encephalitis
  • Liver - hepatitis
  • Patients with serious complications need to be referred to hospital as may need IV antiviral treatment
• Management general advice:

  • Reassure self-limiting and should heal without scarring
  • Advice on how to minimise transmission or autoinoculation:

  1. Avoid kissing/oral sex until lesion fully healed
  2. Don't share items that come into contact with lesion e.g. lip balm
  3. Avoid touching lesions
  4. Take care with contact lenses

  • Avoid triggers e.g. UV light - wear lip balm with SPF
• Symptom relief:

  • Simple analgesia for pain and fever
  • Topical antiviral preparations - acyclovir or penciclovir
  • Topical anaesthetic/analgesic preparations - mouth wash or lip barrier preparations
  • Don't routinely prescribe these products but inform patients they're available OTC if they wish to try
  • Topical preparations can be used from time of onset of prodromal symptoms before vesicles appear until lesions have healed
• Oral antivirals:

  • Acyclovir or vanciclovir
  • Don't routinely prescribe for healthy people with herpes labialis
  • Consider in healthy people with:

  1. Primary oral HSV infection
  2. Recurrent herpes labialis if lesions are severe, frequent or persistent
  3. Recurrent gingivostomatitis (rare)

  • Consider in immunocompromised patients with primary or recurrent oral HSV
  • Patients need to seek medical advice if symptoms worsen or no improvement after 5-7 days
• When to seek advice/refer:

  • People who may benefit from prophylactic oral antivirals:

  1. Immunocompromised with recurrent infection
  2. Frequent, persistent and/or severe episodes
  3. Associated recurrent erythema multiforme

  • Pregnant
  • Lesions refractory to primary care treatment
  • Lesions atypical or diagnosis uncertain