What is the recommended treatment for oral herpes?

Oral Herpes Treatment

For oral herpes (herpes labialis/cold sores), the recommended treatment is valacyclovir 2 grams twice daily for 1 day, taken 12 hours apart, initiated at the earliest symptom of a cold sore. 1, 2

First-Line Treatment Options

Recommended Antiviral Medications:

1. Valacyclovir:

   • Preferred regimen: 2 grams twice daily for 1 day (12 hours apart) 1, 2
   • Benefits: Greater convenience and cost-effectiveness compared to traditional 5-7 day therapy

2. Famciclovir:

   • Alternative option: 1500mg as a single dose 1
   • Reduces median time to healing by 1.8 days compared to placebo

3. Acyclovir:

   • 200mg 5 times daily for 5-7 days 1
   • Particularly recommended during pregnancy due to established safety profile
   • For severe cases: 400mg 5 times daily for 5-7 days 1

Timing of Treatment

Treatment efficacy is highly dependent on timing:

• Initiate therapy at the earliest symptom (tingling, itching, or burning) 1, 2
• Treatment should begin within the first 24 hours of symptom onset when viral titers are highest 1
• Delayed treatment significantly decreases efficacy if started more than 48 hours after symptom onset 1

Special Populations

Immunocompromised Patients:

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

Pregnant Women:

• Acyclovir 200mg 5 times daily for 5-7 days is preferred due to established safety profile 1

Prevention and Suppressive Therapy

For patients with frequent recurrences (≥6 episodes per year), consider suppressive therapy:

• Acyclovir 400mg twice daily 1
• Valacyclovir 500-2000mg twice daily 1

Trigger Avoidance

Counsel patients to avoid known triggers:

• UV radiation (use sunscreen SPF 15 or above) 1, 3
• Fever 1
• Psychological stress 1
• Local trauma 1

Treatment Failure Considerations

If lesions do not begin to resolve within 7-10 days:

• Consider treatment failure and possible resistance 1
• For resistant cases, alternative treatments include topical trifluridine or intravenous foscarnet (40mg/kg three times daily) 4

Topical vs. Oral Therapy

While topical therapy is available, oral antivirals are generally more effective:

• 5% acyclovir cream may reduce lesion duration if applied early, but is less effective than systemic treatment 3, 5
• Topical antivirals cannot reach the site of viral reactivation for prophylactic use 1

Patient Education

Instruct patients to:

• Complete the prescribed course of medication 1
• Keep the area clean and dry to prevent secondary infection 1
• Start treatment at the first sign of prodrome 1
• Understand that antivirals decrease duration of episodes by approximately one day but do not completely abort lesions 6

The evidence clearly shows that early intervention with oral antivirals, particularly valacyclovir in the convenient single-day dosing regimen, provides the most effective management of oral herpes episodes with minimal side effects and maximum convenience.