What is the protocol for managing Herpes Simplex Virus (HSV) infections, specifically cold sores, prior to a medical procedure?

From the Guidelines

For cold sores before a procedure, start antiviral treatment at the first sign of symptoms, ideally 1-2 days before the scheduled procedure, with oral antivirals like valacyclovir, acyclovir, or famciclovir, as recommended by the most recent guidelines 1. The goal of antiviral therapy is to block viral replication, shorten the duration of symptoms, and accelerate healing of the lesions associated with herpes labialis, as discussed in the study by 1. Some key points to consider when managing cold sores before a procedure include:

• Oral antivirals like valacyclovir (1000mg twice daily for 1-3 days), acyclovir (400mg five times daily for 5 days), or famciclovir (1500mg as a single dose) are recommended, as they have been shown to be effective in reducing the severity and duration of cold sore symptoms 1.
• Topical treatments like docosanol 10% cream or acyclovir 5% cream can be applied 5 times daily as an adjunct therapy, but their effectiveness may be limited compared to oral antivirals.
• If the cold sore is active during the procedure, consider rescheduling elective procedures, especially those involving the face or oral cavity, to prevent viral shedding and reduce the risk of spreading the herpes simplex virus to other areas of the body or to healthcare workers, as suggested by 1.
• For urgent procedures, covering the lesion with an occlusive dressing if possible and informing the healthcare provider can help minimize the risk of transmission. It's essential to note that cold sores are most contagious during the weeping stage, and antivirals work by inhibiting viral DNA replication, which is most effective when started early in the outbreak cycle, as discussed in the study by 1.

From the FDA Drug Label

Patients should be advised to initiate treatment at the earliest symptom of a cold sore (e.g., tingling, itching, or burning). There are no data on the effectiveness of treatment initiated after the development of clinical signs of a cold sore (e.g., papule, vesicle, or ulcer). Patients should be instructed that treatment for cold sores should not exceed 1 day (2 doses) and that their doses should be taken about 12 hours apart.

The protocol for cold sores before a procedure is to initiate treatment at the earliest symptom of a cold sore, such as tingling, itching, or burning, and to not exceed 1 day of treatment (2 doses) taken about 12 hours apart 2.

From the Research

Protocol for Cold Sores Before a Procedure

The following points outline the protocol for cold sores before a procedure:

• Antiviral Medications: Antivirals are the typical treatment for cold sores, with acyclovir and valacyclovir being the most commonly prescribed medications 3.
• Valacyclovir Prophylaxis: Valacyclovir has been shown to be effective in preventing HSV reactivation after facial resurfacing procedures, with a recommended dosage of 500 mg twice daily starting the morning before or the morning of the procedure 4.
• Pre-Procedure Protocol: There is no specific protocol outlined in the studies for cold sores before a procedure, but valacyclovir has been shown to be effective in preventing HSV reactivation when started the day before or the day of surgery 4.
• Treatment Options: Other treatment options for cold sores include topical antiviral agents, such as aciclovir 5% cream, and oral antiviral agents, such as famciclovir 5.
• Prevention: Sunscreen has been shown to prevent recurrent HSL induced by experimental ultraviolet light, but its effectiveness in preventing HSL induced by sunlight is uncertain 5.

Key Findings

• Valacyclovir is effective in preventing HSV reactivation after facial resurfacing procedures 4.
• Long-term use of oral antiviral agents can prevent HSL, but the clinical benefit is small 5.
• Topical antiviral agents have little effect on preventing recurrence of HSL 5.
• Sunscreen may prevent recurrent HSL induced by experimental ultraviolet light, but its effectiveness in preventing HSL induced by sunlight is uncertain 5.

Treatment Considerations

• The choice of treatment for cold sores before a procedure should be based on the individual's medical history and the type of procedure being performed.
• Valacyclovir is a well-tolerated medication, but high-dose prophylactic valaciclovir therapy can increase the risk of thrombotic microangiopathy (TMA)-like syndrome in immunocompromised patients 6.
• The efficacy of valacyclovir in preventing HSL has been demonstrated in several studies, but the optimal dosage and duration of treatment are not well established 4, 5.