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Give Aciclovir for herpetic gingivostomatisis

22 Dec, 08 | by Bob Phillips

ACV moleculeDoes oral aciclovir improve clinical outcome in immunocompetent children with primary herpes simplex gingivostomatitis?

A 3 year old previously well boy presents with a fever of 38.6ºc and several ulcers and erosions extending from his lips, along the tongue and cheek, to the back of the throat. The lesions have all appeared within the last 2 days. He has been crying inconsolably over the past 24 hours and is refusing food and drink. Is the use of oral aciclovir is indicated for primary herpes gingivostomatitis in children?

The question has been posed by a team from University Hospital of Wales, in Cardiff. It’s my belief that aciclovir works (based on clinical experience in children with malignant disease) – but the question of ‘is it indicated’ asks more than just ‘does it work’ but ‘should we use it’?

Any views out there?

(You can review the evidence in the report here.)

Acknowledgement:

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  • Jon Jin Kim

    We did this recently for Grand Round in Taunton Hospital.

    Without going into a full critical appraisal, the short answer is Yes – if started within 72 hours of presention. There was a DBRCT in BMJ (Amir J; BMJ. 1997 Jun 21;314(7097):1800-3) which recruited 61 patients with culture proven HSV in a day care unit of a tertiary childrens hospital. There was significant improvements in clinically useful outcomes of time to drinking and eating; fever and period with oral lesions. The patients were given a 7 day oral course. A review done by the same author found 2 other DBRCTs which also showed similar results.

    But as you said, the real question is should we use it? After all the condition is mostly self-limiting with conservative management. Going back to the BMJ paper, the children who were given aciclovir had a median of 3 days less drinking problems (3 days vs 6 days). Therefore the absolute difference of 3 days can be considered significant to the poor child and equally distressed parents. In this case the evidence is clear and I would use aciclovir in this scenario. Would be useful to have a NNT calculated in the paper though.

  • bphillips

    I’m interested by the comment “if started within 72 hours” … does this mean we have evidence that is DOESN’T work if started after that – which is what it imples – or just no clear evidence of effectiveness if started after 3 days?

    Also – 3 days fewer ‘drinking problems’ = improved QoL, no doubt. 7 days of *5/day aciclovir medicine = what? How nasty is it to taste? (I don’t know, fortunately.) Does it really sting lots and lots if your mouth is a mess of ulcers? How does the balance of QoL lie?

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