Is there a benefit to using 1 gram of valacyclovir (Valtrex) twice daily with topical valacyclovir (Valtrex) in sacral herpes, diagnosed late with prior use of topical corticosteroids?

From the Guidelines

For sacral herpes diagnosed late and complicated by topical steroid use, oral valacyclovir (Valtrex) 1 gram twice daily is beneficial and recommended. The combination with topical valacyclovir offers minimal additional benefit. Oral valacyclovir is the mainstay of treatment as it effectively reduces viral shedding, speeds healing, and decreases pain by inhibiting viral DNA synthesis, as supported by the 1998 guidelines for treatment of sexually transmitted diseases 1. The standard treatment duration is 7-10 days for a first episode and 5 days for recurrences. Topical steroids likely worsened the infection by suppressing local immune responses, potentially allowing for viral spread. Patients should discontinue steroids immediately. Adequate hydration and over-the-counter pain relievers like acetaminophen or ibuprofen can help manage discomfort. If pain is severe, a physician may prescribe stronger analgesics. Some key points to consider in the management of sacral herpes include:

• Discontinuation of topical steroids to prevent further immune suppression
• Use of oral valacyclovir as the primary treatment modality
• Consideration of suppressive therapy (valacyclovir 500-1000 mg daily) for frequent recurrences (more than 6 episodes yearly), as discussed in the 1993 sexually transmitted diseases treatment guidelines 1
• Awareness of the potential for antiviral resistance, although this is rare in immunocompetent individuals, as noted in the 2002 U.S. Centers for Disease Control and Prevention guidelines for the treatment of sexually transmitted diseases 1.

From the Research

Treatment of Sacral Herpes with Valacyclovir

• The use of 1 gram of valacyclovir (Valtrex) twice daily with topical valacyclovir (Valtrex) in sacral herpes is not directly addressed in the provided studies.
• However, studies have shown that valacyclovir is effective in treating genital herpes, which is caused by the same virus that causes sacral herpes 2, 3, 4.
• Valacyclovir has been shown to be effective in suppressing recurrent genital herpes, with a dosage of 1 gram daily being effective in suppressing 70 to 80 percent of symptomatic recurrences 2.
• Topical antiviral agents, such as penciclovir, have been shown to be effective in treating herpes simplex virus infections, including genital herpes 5.
• The use of topical corticosteroids prior to treatment with valacyclovir is not addressed in the provided studies, but it is not recommended to use corticosteroids to treat herpes infections as they can exacerbate the condition.

Dosage and Administration

• The dosage of 1 gram of valacyclovir twice daily is higher than the recommended dosage for suppressing recurrent genital herpes, which is 1 gram daily 2.
• The use of topical valacyclovir in combination with oral valacyclovir is not addressed in the provided studies, but it may be beneficial in treating sacral herpes, especially if the infection is severe or widespread 5, 3, 4.

Efficacy and Safety

• Valacyclovir has been shown to be safe and effective in treating herpes simplex virus infections, including genital herpes 2, 3, 4.
• The efficacy and safety of valacyclovir in treating sacral herpes is not directly addressed in the provided studies, but it is likely to be similar to its efficacy and safety in treating genital herpes.
• The use of valacyclovir in combination with topical antiviral agents, such as penciclovir, may be beneficial in treating sacral herpes, especially if the infection is severe or widespread 5, 3, 4.