Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

EM minor

1st line – topical emollient

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ACUTE
|
EM minor
1st line – 

topical emollient

Typical targets or raised edematous papules, with acral distribution, without involvement of mucosal sites, and involving <10% total body surface area.

Topical emollients should be applied to all lesions to hydrate the skin and also act as a protective barrier.

Plus – topical or oral corticosteroids

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ACUTE
|
EM minor
Plus – 

topical or oral corticosteroids

Treatment recommended for ALL patients in selected patient group

Topical or systemic corticosteroids can be used to reduce inflammation and speed resolution.

In EM minor, topical corticosteroids have been shown to benefit clearance of lesions.[1]

Primary options

triamcinolone topical: (0.1%) apply to the affected area(s) twice daily

OR

clobetasol topical: (0.05%) apply to the affected area(s) twice daily

Secondary options

prednisone: 40-60 mg orally once daily for 5-10 days

Consider – withdrawal of suspected causative drug

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ACUTE
|
EM minor
Consider – 

withdrawal of suspected causative drug

Treatment recommended for SOME patients in selected patient group

Review of drug exposure is necessary for all patients with EM. If EM is suspected to be drug-induced, withdrawal of the suspected causative drug is essential.

Drugs that have been associated with EM include certain antibiotics; docetaxel or paclitaxel; immune checkpoint inhibitors; sorafenib; tumor necrosis factor (TNF)-alpha inhibitors; antimalarials; hydroxychloroquine; lenalidomide; methotrexate; anticonvulsants; statins; bisphosphonates; nonsteroidal anti-inflammatory drugs (NSAIDs); metamizole; oral contraceptives; imiquimod; lidocaine; triclocarban; barium contrast.[1][18][19][20][21][22][23]​​​[24][25][26][27]​ However, this list is not exhaustive and you should check your local drug information source.

Plus – sterile dressings

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ACUTE
|
EM minor
|
with open lesions
Plus – 

sterile dressings

Treatment recommended for ALL patients in selected patient group

If any lesions are open, they should be gently cleaned and covered with sterile dressings to prevent secondary bacterial infection.

Plus – oral analgesia

Back
ACUTE
|
EM minor
|
with painful extremity lesions
Plus – 

oral analgesia

Treatment recommended for ALL patients in selected patient group

Analgesics (e.g., acetaminophen, nonsteroidal anti-inflammatory drugs [NSAIDs]) can be taken for general pain and discomfort caused by the lesions.

Primary options

acetaminophen: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

and/or

ibuprofen: 200-400 mg orally every 6-8 hours when required, maximum 2400 mg/day

Consider – oral antiviral therapy

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ACUTE
|
EM minor
|
with herpes simplex infection
Consider – 

oral antiviral therapy

Treatment recommended for SOME patients in selected patient group

Oral antivirals are used for cases of oral herpes simplex virus (cold sores) and genital herpes. Dose depends on indication. See Herpes simplex virus infection (Treatment algorithm).

Primary options

acyclovir: herpes labialis: 200 mg orally five times daily for 5 days; genital herpes (initial episode): 400 mg orally three times daily for 7-10 days; genital herpes (recurrence): 800 mg orally twice daily for 5 days, or 400 mg three times daily for 5 days, or 800 mg orally three times daily for 2 days

OR

valacyclovir: herpes labialis: 2000 mg orally twice daily for 1 day; genital herpes (initial episode): 1000 mg orally twice daily for 7-10 days; genital herpes (recurrence): 500 mg orally twice daily for 3 days, or 1000 mg once daily for 5 days

OR

famciclovir: herpes labialis: 1500 mg orally once daily for 1 day; genital herpes (initial episode): 1000 mg orally once daily for 1 day; genital herpes (recurrence): 125 mg orally twice daily for 5 days, or 1000 mg twice daily for 1 day

Consider – macrolide or doxycycline

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ACUTE
|
EM minor
|
with Mycoplasma pneumonia
Consider – 

macrolide or doxycycline

Treatment recommended for SOME patients in selected patient group

Guidelines on the treatment of atypical pneumonia recommend empiric use of a macrolide or doxycycline for uncomplicated community-acquired pneumonia to ensure coverage of atypical organisms.[47]​ See Mycoplasma pneumoniae infection (Treatment algorithm).

Primary options

azithromycin: 500 mg orally once daily on the first day, followed by 250 mg once daily for 4 days; 500 mg intravenously once daily for 7-10 days

OR

clarithromycin: 500 mg orally every 12 hours for 14-21 days

OR

erythromycin base: 500 mg orally every 6 hours for 14-21 days; 1000 mg intravenously every 6 hours for 14-21 days

OR

doxycycline: 100 mg orally every 12 hours for 14 days

EM major

1st line – topical emollient

Back
ACUTE
|
EM major
1st line – 

topical emollient

Typical targets or raised edematous papules, with acral distribution, plus involvement of 1 or more mucosal sites, and involving <10% total body surface area.

Topical emollients should be applied to all lesions to hydrate the skin and to act as a protective barrier.

Plus – oral or intravenous corticosteroids

Back
ACUTE
|
EM major
Plus – 

oral or intravenous corticosteroids

Treatment recommended for ALL patients in selected patient group

Oral corticosteroids can be used to reduce inflammation.

In hospitalized patients, intravenous corticosteroids may be required. Careful prevention or treatment of secondary bacterial infections is necessary.

Primary options

prednisone: 40-60 mg orally once daily for 5-10 days

Secondary options

methylprednisolone sodium succinate: 1 mg/kg intravenously every 8 hours

Consider – withdrawal of suspected causative drug

Back
ACUTE
|
EM major
Consider – 

withdrawal of suspected causative drug

Treatment recommended for SOME patients in selected patient group

Review of drug exposure is necessary for all patients with EM. If EM is suspected to be drug-induced, withdrawal of the suspected causative drug is essential.

Drugs that have been associated with EM include certain antibiotics; docetaxel or paclitaxel; immune checkpoint inhibitors; sorafenib; tumor necrosis factor (TNF)-alpha inhibitors; antimalarials; hydroxychloroquine; lenalidomide; methotrexate; anticonvulsants; statins; bisphosphonates; nonsteroidal anti-inflammatory drugs (NSAIDs); metamizole; oral contraceptives; imiquimod; lidocaine; triclocarban; barium contrast.[1][18][19][20][21][22][23]​​​[24][25][26][27]​ However, this list is not exhaustive and you should check your local drug information source.

Plus – sterile dressings

Back
ACUTE
|
EM major
|
with open lesions
Plus – 

sterile dressings

Treatment recommended for ALL patients in selected patient group

If any lesions are open, they should be gently cleaned and covered with sterile dressings to prevent secondary bacterial infection.

Plus – oral analgesia

Back
ACUTE
|
EM major
|
with painful extremity lesions
Plus – 

oral analgesia

Treatment recommended for ALL patients in selected patient group

Analgesics (e.g., acetaminophen, nonsteroidal anti-inflammatory drugs [NSAIDs]) can be taken for general pain and discomfort caused by the lesions.

Primary options

acetaminophen: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

and/or

ibuprofen: 200-400 mg orally every 6-8 hours when required, maximum 2400 mg/day

Plus – topical lidocaine and mouthwash

Back
ACUTE
|
EM major
|
with painful oral lesions
Plus – 

topical lidocaine and mouthwash

Treatment recommended for ALL patients in selected patient group

Magic mouthwash is the name for a mouthwash containing a number of possible formulations. A formulation recommended for symptomatic relief of painful oral lesions would contain local anesthetic (lidocaine), an antihistamine (diphenhydramine), and an antacid. It is compounded by a pharmacist.

Primary options

lidocaine oropharyngeal viscous solution: (2%) 15 mL every 3 hours when required (swish around in mouth and spit out), maximum 8 doses/day

Plus – intravenous fluids

Back
ACUTE
|
EM major
|
with volume depletion
Plus – 

intravenous fluids

Treatment recommended for ALL patients in selected patient group

Patients may become volume depleted due to painful oral lesions restricting fluid intake.

Plus – catheterization

Back
ACUTE
|
EM major
|
with urethral blockage
Plus – 

catheterization

Treatment recommended for ALL patients in selected patient group

The urethra may become blocked due to sloughing.

Consider – antivirals

Back
ACUTE
|
EM major
|
with herpes simplex infection
Consider – 

antivirals

Treatment recommended for SOME patients in selected patient group

Oral antivirals are used for cases of oral herpes simplex virus (cold sores) and genital herpes. Dose depends on indication. See Herpes simplex virus infection (Treatment algorithm).

Primary options

acyclovir: herpes labialis: 200 mg orally five times daily for 5 days; genital herpes (initial episode): 400 mg orally three times daily for 7-10 days; genital herpes (recurrence): 800 mg orally twice daily for 5 days, or 400 mg three times daily for 5 days, or 800 mg orally three times daily for 2 days

OR

valacyclovir: herpes labialis: 2000 mg orally twice daily for 1 day; genital herpes (initial episode): 1000 mg orally twice daily for 7-10 days; genital herpes (recurrence): 500 mg orally twice daily for 3 days, or 1000 mg once daily for 5 days

OR

famciclovir: herpes labialis: 1500 mg orally once daily for 1 day; genital herpes (initial episode): 1000 mg orally once daily for 1 day; genital herpes (recurrence): 125 mg orally twice daily for 5 days, or 1000 mg twice daily for 1 day

Consider – macrolide or doxycycline

Back
ACUTE
|
EM major
|
with Mycoplasma pneumonia
Consider – 

macrolide or doxycycline

Treatment recommended for SOME patients in selected patient group

Guidelines on the treatment of atypical pneumonia recommend empiric use of a macrolide or doxycycline for uncomplicated community-acquired pneumonia to ensure coverage of atypical organisms.[47]​ See Mycoplasma pneumoniae infection (Treatment algorithm).

Primary options

azithromycin: 500 mg orally once daily on the first day, followed by 250 mg once daily for 4 days; 500 mg intravenously once daily for 7-10 days

OR

clarithromycin: 500 mg orally every 12 hours for 14-21 days

OR

erythromycin base: 500 mg orally every 6 hours for 14-21 days; 1000 mg intravenously every 6 hours for 14-21 days

OR

doxycycline: 100 mg orally every 12 hours for 14 days

ONGOING

recurrent EM

1st line – suppressive antiviral therapy

Back
ONGOING
|
recurrent EM
1st line – 

suppressive antiviral therapy

Intended for prevention of recurrences in patients with recurrent illness. If the immediate dose of valacyclovir taken at first sign of oral herpes simplex infection does not control symptoms, then valacyclovir may need to be continued for at least 6 months.

Doubling the dose may be required to control recurrences.[41]

Acyclovir is used for patients who need liquid medications.

Primary options

valacyclovir: 1000 mg orally once daily for 6 months, or 500 mg orally twice daily for 6 months

Secondary options

acyclovir: 400 mg orally twice daily for 6 months

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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