What is the treatment for an early oral herpes simplex virus (HSV) infection, also known as a cold sore?

From the Guidelines

The most effective treatment for an early oral herpes simplex virus (HSV) infection or cold sore is to start antiviral medications such as acyclovir, valacyclovir, or famciclovir at the first sign of symptoms, during the tingling or burning stage before the blister appears. These medications have been shown to reduce the duration and severity of symptoms when started early 1. The typical dosage for acyclovir is 400 mg taken orally five times daily for 5 days, while valacyclovir is usually prescribed as 2 grams twice daily for one day, and famciclovir as 1500 mg as a single dose.

Some key points to consider when treating an early oral HSV infection include:

• Starting treatment as soon as possible to ensure optimal therapeutic benefit 1
• Using antiviral medications to inhibit viral DNA replication and prevent the virus from multiplying
• Considering over-the-counter options such as docosanol 10% cream (Abreva) for mild symptoms
• Using pain relief measures such as topical anesthetics containing benzocaine or lidocaine
• Applying cold compresses to reduce swelling and avoiding acidic or salty foods to prevent irritation

It's also important to note that for people with frequent outbreaks (more than six per year), daily suppressive therapy with antivirals may be recommended to reduce recurrences 1. However, the decision to start suppressive therapy should be made on a case-by-case basis, taking into account the individual's medical history and the severity of their symptoms.

In terms of specific treatment options, a meta-analysis of five placebo-controlled and two dose-comparison studies evaluating acyclovir, famciclovir, or valacyclovir found that oral antiviral therapy decreases outbreak duration and associated pain by 1 day 1. Additionally, a controlled trial showed that acyclovir/hydrocortisone cream significantly reduced the frequency of both ulcerative and nonulcerative recurrences in immunocompetent adults 1.

Overall, the goal of treatment for an early oral HSV infection is to reduce the duration and severity of symptoms, and to improve quality of life for individuals affected by the condition. By starting antiviral medications early and using a combination of treatment strategies, individuals can effectively manage their symptoms and reduce the impact of the infection on their daily lives.

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 treatment for an early oral herpes simplex virus (HSV) infection, also known as a cold sore, is to initiate valacyclovir treatment at the earliest symptom (e.g., tingling, itching, or burning) and take it for 1 day (2 doses), with doses taken about 12 hours apart 2.

• Key points:
  • Initiate treatment early
  • Take 2 doses, 12 hours apart
  • Do not exceed 1 day of treatment
• Important note: 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) 2.

From the Research

Treatment Options for Early Oral Herpes Simplex Virus (HSV) Infection

• The treatment for early oral HSV infection, also known as a cold sore, typically involves antiviral therapy to shorten the duration of pain and discomfort, hasten healing, and reduce viral shedding 3.
• Episodic treatment is warranted, especially if the patient desires treatment for cosmetic purposes or for relief of pain, and should be initiated promptly, ideally in the prodromal stage and no later than 48 hours from the onset of lesions to achieve optimal results 3.

Antiviral Medications

• Oral antiviral agents, such as acyclovir (Zovirax), valacyclovir (Valtrex), and famciclovir (Famvir), are superior to topical antiviral therapy for episodic treatment of herpes labialis 3.
• Topical antiviral agents, such as 5% acyclovir cream/ointment (Zovirax) ± hydrocortisone (Xerese), 1% penciclovir (Denavir) cream, and 50 mg Buccal Adhesive Tablet (ABT-50 mg), can also be used for episodic treatment of herpes labialis, but are not effective in preventing recurrent herpes labialis 3.
• A study found that ME-609, a combination of 5% acyclovir and 1% hydrocortisone, prevented progression of cold sores to ulcerative lesions and significantly reduced the cumulative lesion area compared to acyclovir and placebo 4.

Prevention of Recurrent Herpes Labialis

• Long-term use of oral antiviral agents can prevent herpes labialis, but the clinical benefit is small, and there is no increased risk of adverse events 5.
• Topical antiviral agents and other interventions, such as sunscreen, thymopentin, low-level laser therapy, and hypnotherapy, have limited or no evidence of efficacy in preventing recurrent herpes labialis 5, 6.
• A review of antiviral therapy for herpes labialis, genital herpes, and herpes zoster found that oral acyclovir, valacyclovir, and famciclovir are efficacious and safe for the treatment of the first episode and recurrent genital herpes, and are useful as suppressive therapy for individuals with frequent genital herpes recurrences 7.