Antivirals and Ulcerative Lesions

Advances in the pharmacological treatment of viral infections lag behind the treatment of bacterial or fungal infections. The reason is due to the difficulty in attaining adequate degrees of selective toxicity. Since virus replication uses the same metabolic mechanisms essential for the function of normal cells, it was difficult to find drugs that would inhibit viral growth without killing the host. However recent advances in the research of viral replication have lead to discovery of agents useful in antiviral activity in the oral cavity. The agents are not highly effective and are best used as soon as symptoms first appear. Systemic supportive therapy should be administered in conjunction with antivirals which includes forced fluids, high concentration protein, vitamin and mineral food supplements and rest. Viral infections may become secondarily infected with bacteria requiring antibiotics.

Oral viral infections are most commonly caused by the herpes simplex virus. The herpes zoster or herpes varicella–zoster virus can cause similar viral eruptions involving the oral mucosa.

Diagnosis of oral viral infections begins by evaluation of presenting signs and symptoms. A distinction must be made between lesions associated with herpes and aphthous ulcers which do not have a viral etiology.

Viral lesions (Herpetic gingivostomatitis) are characterized by an initial acute onset of vesicular eruptions on the soft tissues that quickly rupture into small ulcerations that are covered by a yellowish gray pseudomembrane surrounded by an erythematous halo. The ulcers may coalesce to form larger irregular ulcerations. The lesions are found on the gingival, tongue, palate lips (labialis), buccal mucosa, tonsils and posterior pharynx. The ulcers gradually heal over 7-10 days without scarring. The disease is accompanied by high fever, malaise, irritability, headache and pain in the mouth during the first three days of onset. It usually appears in children between the ages of six months and four years. Treatment consists of administration of acyclovir and supportive therapy.

Contraindications: Hypersensitivity to acyclovir, valacyclovir, or any component of the formulation.

Warnings/Precautions: Use with caution in immunocompromised patients. Safety and efficacy of oral formulations have not been established in pediatric patients < 2years of age. The ointment is for external use only to the lips and face. Do not apply to the eye or inside the nose or mouth. Treatment should begin at the first sign of symptoms.

The oral systemic dose of acyclovir (only given in severe cases of HSV) is:

Children ≥ 2 years and ≤ 40 kg: 20 mg /kg/dose (up to 800 mg /dose) 4 times/day for 5 days
Children > 40 kg and adults: 800 mg/dose 4 times/day for 5 days

Recurrent aphthous ulcers (aphthous stomatitis) are painful ulcerations that usually occur after the sixth year of age. The exact etiology is unknown. Predisposing factors include trauma, genetics, infections, allergy, systemic diseases, hormonal disturbances, emotional stress acquired immune deficiency syndrome and others. The non-keratinized mobile oral mucosa (buccal mucosa, labial mucosa, tongue, floor of the mouth, soft palate and uvula) is most frequently affected. The lesions are clinically characterized by a shallow, round painful ulcer 3-6 mm in diameter. The ulcer is covered by a yellow-white membrane and is surrounded by thin red halo. The lesions may be single or multiple and heal without scarring. Unlike viral infections there are no accompanying systemic symptoms (high fever, malaise, etc.). Treatment is limited to topical treatment to reduce the pain and shorten the course.

Sample prescriptions:

Herpes Simplex (Primary)

Rx: Acyclovir (Zovirax®) 200 mg capsules
Disp: 50 or 60 capsules
Sig: Take 1 capsule 5 times/day for 10 days or 2 capsules/3 times/day for 10 days

Herpes Simplex (Labialis/Recurrent)

Rx: Acyclovir (Zovirax®) 5% for Herpes labialis (cold sores)
Disp: 2 gm
Sig: Apply 5 times/day during waking hours for 4 days (begin when symptoms first appear)

Rx: Penciclovir (Denavir®) 5% ointment
Disp: 2 gm
Sig: Apply locally as directed to lesion every 2 hours during waking hours (begin when symptoms first appear)

Rx: Docosanol (Abreva®) OTC ≥ 12 years and adults
Disp: 2 gm tube
Sig: Apply to lesion 5 times/day during waking hours for 4 days (begin when symptoms first appear)

Recurrent Aphthous Stomatitis
Liquid volumes are prescribed for a 2 week course

Rx: Orabase® Protective Barrier (OTC)
Disp: 1 package
Sig: Apply locally as needed every 6 hours.

Rx: Diphenhydramine liquid (Benadryl® / Kaopectate or Maalox) / Lidocaine viscous (mix 1/3,1/3,1/3)
Disp: 8-24 oz (Pharmacist may charge for each 8 oz bottle of the individual ingredients)
Sig: Rinse 1-2 teaspoonfuls every 2 hours and expectorate.

Rx: Triamcinolone acetonide (Kenalog®) in Orabase 0.1%
Disp: 5 gm tube
Sig: Apply locally as directed to the lesion after each meal and at bedtime.

Rx: Fluocinonide (Lidex®) 0.05%
Disp: 45 g tube
Sig: Apply locally as directed to lesion 4 times/day.