Acyclovir for herpes simplex gingivostomatitis in children

American Family Physician,  Nov 1, 1997  by Anne D. Walling

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Many children with severe primary herpetic gingivostomatitis refuse to eat or drink during the acute phase of the illness, which may necessitate hospital admission to prevent or treat dehydration. Acyclovir therapy has shown promising results in other forms of pediatric herpes infection and in a few small studies of oral herpetic lesions. Amir and colleagues conducted a randomized, double-blind, placebo-controlled trial of oral acyclovir in children with herpes simplex gingivostomatitis.

The 61 children who completed the study ranged in age from one to six years and were referred to an Israeli pediatric unit by community physicians and emergency room personnel. The clinical lesions had erupted within 72 hours of presentation. All of the children were clinically assessed, including the number and severity of lesions, the presence of fever and the degree of difficulty in eating and drinking.

After obtaining swabs for viral culture and blood samples for serologic confirmation of infection, the investigators randomly assigned the children to treatment with acyclovir suspension, 15 mg per kg five times daily for seven days, or placebo given by the same regimen. The children were assessed again on days 3, 6 and 8, including evaluation with repeated viral cultures. If the symptoms persisted, assessments were continued every two to three days until the resolution of symptoms. A repeat serologic sample was drawn five to nine days after completion of therapy. Medication compliance was checked by inspection of bottles of suspension.

Oral lesions resolved significantly more rapidly in the children treated with acyclovir than in the children who received placebo. The median duration of lesions in the acyclovir-treated children was four days (range: two to 12 days), compared with a median duration of 10 days (range: three to 15 days) in those receiving placebo.

By day 8, only two children in the treatment group had persistent lesions, compared with 21 children in the placebo group. Fever resolved significantly earlier in the children treated with acyclovir. Fever disappeared in a median of one day in the treatment group, compared with three days in the placebo group. Acyclovir-treated children also had more rapid resolution of clinical symptoms. Extraoral lesions did not continue to develop and resolved rapidly in the treated children, whereas they continued to develop in 12 of the placebo-treated children and had a median duration of 5.5 days.

Although all of the children had difficulty eating and drinking on entry into the study, by day 8, only two children in the treatment group had eating problems and one had persistent difficulty in drinking. In the placebo group, 14 children continued to have eating difficulties and nine continued to have problems with fluid intake by day 8. Three children from the placebo group required hospital admission during the study because of dehydration.

Positive viral cultures were obtained for a median of one day (range: one to three days) in the acyclovir-treated children but persisted for a median of five days (range: one to 10 days) in the placebo group. Follow-up at 16 months revealed recurrence in only one child (a member of the placebo group). Compliance with therapy was high, and no side effects were detected.

The authors conclude that oral acyclovir shortened the period of infection when treatment was initiated within three days of the development of symptoms. Further studies are needed to clarify the optimal dose, to establish the effect of treatment on long-term immunity and to establish any risk of the virus developing resistance to acyclovir if the agent is widely used.

Amir J, et al. Treatment of herpes simplex gingivostomatitis with aciclovir in children: a randomised double blind placebo controlled study. BMJ 1997;314:1300-3.

COPYRIGHT 1997 American Academy of Family Physicians
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