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Oral & Dental Health

Herpes Infections (Oral/Facial)

Infections caused by Herpes Simplex Virus (HSV-1 usually, sometimes HSV-2) or Varicella Zoster Virus (VZV), affecting the face and oral cavity.

Also known as: Cold Sores, Fever Blisters, Herpetic Gingivostomatitis, Oral Herpes, Shingles (Facial/Oral)

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Referral and warning signs

When to refer

Refer if: Severe symptoms, dehydration (primary HSV). Immunocompromised patient. Suspected Herpes Zoster Ophthalmicus (eye involvement - URGENT Ophthalmology referral). Complications develop (secondary infection, PHN, facial palsy). Diagnosis uncertain.

Red flags

  • Eye involvement with facial shingles (lesions on tip of nose - Hutchinson's sign).
  • Signs of dehydration.
  • Severe systemic symptoms.
  • Facial palsy associated with ear/facial rash (Ramsay Hunt).

Signs and symptoms

  • Primary Herpetic Gingivostomatitis (HSV - Initial Infection, usually children):
  • - Fever, malaise, irritability, lymphadenopathy.
  • - Multiple painful vesicles that rupture quickly to form shallow, yellowish ulcers.
  • - Affects ANY oral mucosal surface (gingiva, tongue, lips, buccal mucosa, palate).
  • - Marked gingival inflammation and bleeding.
  • - Difficulty eating/drinking.
  • Recurrent Herpes Labialis (HSV - 'Cold Sores', 'Fever Blisters'):
  • - Prodrome of tingling, itching, or burning at site (usually vermilion border of lip).
  • - Eruption of cluster of small vesicles.
  • - Vesicles rupture, crust over, heal in 7-10 days.
  • - Triggered by stress, sun exposure, illness, trauma.
  • Intraoral Recurrent Herpes (HSV): Less common, small vesicle clusters rupture to form ulcers, typically on KERATINIZED mucosa (hard palate, attached gingiva).
  • Herpes Zoster (Shingles - VZV Reactivation):
  • - Unilateral pain (often burning, stabbing) along a trigeminal nerve dermatome (V1, V2, or V3).
  • - Followed by eruption of vesicles in the same dermatome distribution.
  • - Oral lesions (vesicles/ulcers) occur if maxillary (V2) or mandibular (V3) divisions affected - STRICTLY UNILATERAL, stops at midline.
  • - May have associated facial skin lesions.
  • - Post-Herpetic Neuralgia (persistent pain after rash resolves) can occur.

Risk factors

  • HSV: Exposure to virus (very common). Reactivation triggers (stress, sun, illness). Immunosuppression (more severe/frequent).
  • VZV: Prior chickenpox infection. Increasing age. Immunosuppression (HIV, steroids, chemotherapy).

Diagnosis

Clinical assessment

Diagnosis usually based on characteristic clinical appearance and distribution of lesions. History of prodrome, recurrence (HSV labialis), or unilateral dermatomal pattern (Zoster) is helpful.

Differential diagnosis

  • Aphthous Ulcers (non-keratinized mucosa usually, no vesicles).
  • Hand, Foot, and Mouth Disease (Coxsackie virus - lesions also on hands/feet).
  • Herpangina (Coxsackie - posterior oropharynx).
  • Erythema Multiforme.
  • Pemphigus/Pemphigoid.
  • ANUG (interdental papillae primarily).
  • Traumatic ulcers.

Investigations

  • Usually clinical diagnosis.
  • Viral culture or PCR from vesicle fluid (confirmatory, rarely needed clinically).
  • Tzanck smear (shows multinucleated giant cells - less sensitive/specific).

Diagnostic criteria

Clinical presentation with characteristic vesicular eruption +/- typical distribution (lip border, dermatome).

Management

Non-pharmacological management

  • Maintain hydration and nutrition (soft diet, fluids).
  • Avoid touching lesions/spreading.
  • Antiseptic mouthwashes (Chlorhexidine, salt water) may help prevent secondary infection.

Pharmacological treatment

  • Pain Relief: Paracetamol, NSAIDs. Topical anaesthetics (Lidocaine gel) before eating.
  • Primary Herpetic Gingivostomatitis (HSV):
  • - Usually supportive care (fluids, analgesia).
  • - Consider Oral Acyclovir (especially if severe, immunocompromised, or started within 72h): Dose varies, e.g., 200-400mg 5 times/day for 5-7 days (Adult). Pediatric dosing weight-based. (LOC: HC2/3)
  • Recurrent Herpes Labialis (HSV):
  • - Topical Antiviral Creams (Acyclovir, Penciclovir): Apply frequently at first sign (prodrome). May shorten duration slightly.
  • - Oral Acyclovir (e.g., 400mg TID) or Valacyclovir/Famciclovir started during prodrome may abort or shorten episode (specialist/patient initiated).
  • Herpes Zoster (Shingles - Oral/Facial):
  • - Oral Antivirals (Start within 72 hours of rash onset): Acyclovir 800mg 5 times/day for 7-10 days. OR Valacyclovir 1g TID for 7 days. OR Famciclovir 500mg TID for 7 days. (LOC: HC4)
  • - Analgesia: May require strong analgesics including neuropathic agents (Amitriptyline, Gabapentin) for acute pain or post-herpetic neuralgia (PHN).
  • - Consider systemic steroids (e.g., Prednisolone) early in course WITH antivirals for severe pain or facial palsy (Ramsay Hunt) - specialist decision.
  • - Topical antibiotics if secondary bacterial infection of skin lesions.
  • - Refer urgently to Ophthalmology if eye involved (Herpes Zoster Ophthalmicus).

Monitoring

Monitor for dehydration (primary HSV). Monitor pain control. Monitor for secondary infection. Assess for PHN after Zoster.

Complications

  • Dehydration (primary HSV).
  • Secondary bacterial infection.
  • Erythema multiforme (HSV trigger).
  • Herpetic whitlow (finger infection).
  • Eczema herpeticum (in patients with eczema).
  • Herpes Zoster complications: Post-Herpetic Neuralgia (PHN), Ramsay Hunt Syndrome (facial palsy + Zoster), Ophthalmic involvement (vision loss), CNS complications (rare).

Prevention

  • HSV: Avoid close contact (kissing, sharing utensils) during active outbreaks. Sunscreen may reduce recurrence of herpes labialis.
  • VZV: Varicella (chickenpox) vaccination. Zoster (shingles) vaccination for older adults (>50-60 yrs).

Patient education

  • Explanation of viral cause (HSV vs VZV).
  • Contagiousness (HSV during outbreaks).
  • Natural history and recurrence (HSV).
  • Symptomatic relief measures.
  • How to use antiviral medication if prescribed (importance of starting early for Zoster).
  • Potential for Post-Herpetic Neuralgia (Zoster).
  • When to seek further care.

Uganda-specific notes

Oral herpes common. Primary HSV gingivostomatitis seen in children. Herpes zoster prevalence increases with age and HIV. Acyclovir availability crucial for Zoster and severe HSV. Recognize Ramsay Hunt and Herpes Zoster Ophthalmicus as emergencies requiring referral.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 23, Section 23.3.2

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