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Clinical Summary

Oral herpes simplex may present acutely as a primary gingivostomatitis or as a recurrence. Painful vesicular eruptions on the oral mucosa, tongue, palate, vermilion borders, and gingiva are highly characteristic. A 2- to 3-day prodromal period of malaise, fever, and cervical adenopathy is common. The vesicular lesions rupture to form a tender ulcer with yellow crusting and an erythematous margin. Pain may be severe enough to cause drooling and odynophagia, which can discourage eating and drinking, particularly in children. The disease tends to run its course in a 7- to 10-day period with nonscarring resolution of the lesions. Recurrent herpes labialis may present with an aura of burning, itching, or tingling prior to vesicle formation. Oral trauma, sunburn, stress, and any variety of febrile illnesses can precipitate this condition. Oral erythema multiforme or Stevens-Johnson syndrome, aphthous lesions, oral pemphigus, and hand-foot-mouth (HFM) syndrome are in the differential diagnosis. It should be noted that aphthous ulcers tend to occur on movable oral mucosa and rarely on immovable mucosa (ie, hard palate and gingiva). The vermilion border is a characteristic location for herpes labialis as opposed to aphthous lesions. Posterior oropharyngeal ulcerations with associated hand and foot lesions help to define HFM syndrome.


Herpes Simplex Virus (HSV) Stomatitis. Note the extensive painful ulcerations on the patient’s lower lip. A prodromal period of fever, malaise, and cervical adenopathy may herald the onset of these painful ulcerations. (Photo contributor: Lawrence B. Stack, MD.)

Management and Disposition

Supportive care with rehydration and pain control is the mainstay of therapy. Temporary pain relief may be achieved with topical analgesics. Viscous lidocaine may be used as an oral rinse in an age-appropriate dose and form. Oral antiviral agents may be useful with primary infections. Secondary infection of herpetic lesions should be treated with antibiotics.


  1. Fatal viremia and systemic involvement may occur in infants and children with herpetic gingivostomatitis.

  2. Primary acute oral herpetic infection occurs most commonly in children and young adults.

  3. Initiation of suppressive therapy with oral antivirals should be considered within the 1st 72 hours from symptom onset.


HSV Stomatitis. Extensive vesicular lesions along the vermilion border and surrounding tissues are consistent with HSV infection. (Photo contributor: Frank Birinyi, MD.)

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