Pediatric Herpetic Keratitis: Recurrence Predictors and Antiviral Prophylaxis Outcomes

BACKGROUND: Herpetic keratitis (HK) is associated with frequent recurrences and vision-threatening sequelae, yet predictors of relapse remain poorly defined in children. Evidence on antiviral prophylaxis effectiveness is limited. We aimed to characterize recurrence patterns, identify predictors of recurrent disease, and evaluate prophylaxis-associated recurrence reduction in a pediatric HK cohort. METHODS: We retrospectively studied patients aged <18 years with HK at a tertiary pediatric referral center (2014-2026). Univariable and multivariable analyses identified predictors of recurrence and evaluated prophylaxis-associated recurrence reduction. RESULTS: Seventy-four children were included. Median age at first episode was 7 years (interquartile range [IQR] 4.0-9.5). Median follow-up was 2 years (IQR 1.0-5.5). Disease was bilateral in 4 children (5%). Recurrence occurred in 46/74 (62%), with a median of 3 episodes (IQR 2-5.8) among recurrent cases and a maximum of 15 in a single patient. In multivariable analysis, atopic phenotype was independently associated with both any recurrence (aOR 3.37, 95% CI 1.03-11.08; p = 0.045) and multiple recurrences (aOR 7.52, 95% CI 1.36-41.6; p = 0.021). Oral antiviral prophylaxis was prescribed in 50 (68%) and was associated with a 69% reduction in mean recurrence frequency (2.70 vs 0.84 episodes per patient; p < 0.001). Recurrence despite prophylaxis occurred in 29 of 50 children (58%), with no clinical predictor identified. Ocular sequelae were documented in 39 (53%) and were more frequent among relapsing children (p = 0.031). CONCLUSIONS: Pediatric HK is characterized by a high burden of recurrent disease and ocular sequelae. Children with an atopic phenotype had more frequent recurrences and may need closer follow-up, with a lower threshold for starting antiviral prophylaxis and a higher one for stopping it. This approach needs prospective testing before it can be recommended. Weight-based antiviral prophylaxis was associated with reduction in recurrence frequency, although recurrence despite antiviral prophylaxis remained common. Further studies should optimize prophylaxis and clarify the atopy-recurrence link in pediatric HK.