What is the recommended treatment for herpes labialis?

Treatment of Herpes Labialis

Valacyclovir 2g twice daily for 1 day is the most effective treatment for herpes labialis, significantly reducing healing time and symptom duration compared to placebo or topical treatments. 1

First-Line Treatment Options

Oral Antivirals

• Valacyclovir: 2g twice daily for 1 day (preferred regimen)

  • Reduces median duration of episode by approximately half a day compared to placebo 1
  • Most effective when started during prodromal phase (tingling, burning, itching)

• Famciclovir: 1500mg as a single dose

  • Reduces median time to healing by 1.8 days (4.4 days vs 6.2 days with placebo) 1

• Acyclovir: 200mg 5 times daily for 5-7 days

  • Particularly recommended during pregnancy due to established safety profile 1
  • Reduces duration of pain by 36% and healing time by 27% when started during prodrome or erythema stage 2

Topical Treatments

• Penciclovir cream (Denavir):

  • Apply every 2 hours while awake for 4 days
  • Reduces mean duration of lesions by approximately half a day compared to placebo 3
  • Should be started at earliest sign of cold sore (tingling, redness, itching)

• Acyclovir cream (5%):

  • Apply 5 times daily for 4 days
  • Reduces episode duration by approximately half a day 4
  • Efficacy demonstrated whether initiated early (prodrome/erythema) or late (papule/vesicle)

Treatment Algorithm Based on Clinical Presentation

1. Prodromal Phase (First 24 Hours)

• Start oral antiviral immediately - this is critical as peak viral titers occur in first 24 hours 1
• Valacyclovir 2g twice daily for 1 day (preferred)
• If oral medication unavailable, apply topical treatment immediately

2. Vesicular Phase

• Continue oral antiviral if started during prodrome
• If not yet treated, start oral antiviral immediately
• Consider topical anesthetics for pain relief

3. Crusting/Healing Phase

• Complete prescribed course of medication
• Keep area clean and dry to prevent secondary infection

Special Populations

Immunocompromised Patients

• Higher doses of acyclovir (400mg five times daily)
• Longer treatment duration (7-10 days)
• Consider hospitalization if severe symptoms or dissemination occur 1

Pregnant Women

• Acyclovir 200mg 5 times daily for 5-7 days is preferred
• Has established safety profile during pregnancy 1

Preventive Measures for Frequent Recurrences

• For patients with >6 episodes/year, consider suppressive therapy:
  • Acyclovir 400mg twice daily or
  • Valacyclovir 500-2000mg twice daily 1
• Apply sunscreen (SPF 15 or above) to prevent UV-induced recurrences
• Counsel patients to avoid triggers: UV radiation, stress, fever, and local trauma

Important Caveats

• Treatment should be initiated as soon as possible after symptom onset for optimal effect 5
• Topical treatments alone provide only modest benefits, reducing duration by approximately half a day 3, 4
• Combination of acyclovir with hydrocortisone shows no significant advantage over acyclovir alone and should be avoided due to potential risks of corticosteroids 6
• If lesions do not begin to resolve within 7-10 days, consider treatment failure and possible resistance 1
• Topical antivirals are not effective prophylactically as they cannot reach the site of viral reactivation 5

Remember that early intervention is key to treatment success, as the natural healing process begins within the first 24 hours of onset. The most significant clinical benefit comes from oral antivirals started during the prodromal phase.