Prophylactic oral antiviral treatment should be considered if the patient is:
- immunocompromised and has troublesome recurrent oral herpes simplex infection
- has frequent (6 or more episodes in one year), persistent and/or severe episodes of recurrent oral herpes simplex infection
- has herpes simplex associated with recurrent erythema multiforme.
Those with atypical lesions or in whom the diagnosis is uncertain (but thought to be benign) should be referred routinely to Oral Medicine. Patients with unexplained ulceration of the oral mucosa persisting > 3 weeks should be referred as urgent, suspicious of cancer to Oral and Maxillofacial Surgery.
Severe or recurrent genital HSV infection should be referred to Sexual and Reproductive Health Services.
C.M & N.B – 5-10-26
Who to refer:
Patients with confirmed recurrent non-genital HSV infection which does not respond to first line prophylactic oral antiviral therapy.
Immunocompromised patients with recurrent non-genital HSV infection.
Who not to refer:
Patients with
- atypical lesions or where the diagnosis is uncertain, but thought to be benign – refer to Oral Medicine
- unexplained ulceration of the oral mucosa persisting > 3 weeks – refer to OMFS as urgent, suspicious of cancer.
- severe or recurrent genital HSV infection – refer to Recurrent Genital Herpes guidance.
- recurrent (6 or more episodes per year) uncomplicated HSV infection with no history of immunocompromise – start first line prophylactic antivirals as per BNF
- recurrence of HSV infection following cessation of prophylaxis – patients can be restarted on prophylaxis without further discussion.
How to refer:
Via Sci Gateway to Infectious Diseases at the Western General Hospital
Guidance on the management of uncomplicated oral HSV is available as a NICE CKS summary. Patients should be offered screening for HIV infection. Prophylactic treatment regimens for recurrent HSV infection can be found in the BNF.
In immunocompetent patients, the first line treatment is aciclovir 400mg twice daily. Breakthrough infections should be treated with standard courses of antiviral therapy before reverting to prophylactic dose.
