What is the treatment for Herpes Simplex Virus (HSV)?

Treatment of Herpes Simplex Virus (HSV) Infections

For HSV infections, antiviral therapy with valacyclovir, acyclovir, or famciclovir is the standard treatment, with specific dosing regimens based on whether the infection is initial, recurrent, or requires suppressive therapy. 1

First-Line Treatment Options

Initial HSV Episodes

• Valacyclovir: 1000 mg twice daily for 10 days 2
• Acyclovir: 800 mg five times daily for 7-10 days 1
• Famciclovir: 500 mg three times daily for 7 days 1

Recurrent HSV Episodes

• Valacyclovir: 500 mg twice daily for 3-5 days 1, 2
• Acyclovir: 800 mg three times daily for 2 days 3 or 800 mg five times daily for 5 days 1
• Famciclovir: 500 mg twice daily for 5 days 1

Suppressive Therapy (for frequent recurrences)

• Valacyclovir: 1000 mg once daily or 500 mg once daily 1, 2
• Acyclovir: 400 mg twice daily 1, 4
• Famciclovir: 250 mg twice daily 1

Treatment Algorithm Based on Clinical Presentation

1. For primary/initial HSV infection:

   • Start with higher doses for longer duration (7-10 days)
   • Monitor for complete healing of lesions
   • In immunocompromised patients, continue treatment until complete healing 1

2. For recurrent episodes:

   • Start treatment at first sign of prodrome for maximum effectiveness
   • Shorter treatment courses (3-5 days) are effective 1, 5
   • Valacyclovir is the only antiviral approved for a 3-day regimen 6

3. For frequent recurrences (≥6 per year):

   • Consider daily suppressive therapy
   • Valacyclovir is the only antiviral approved for once-daily suppressive therapy 6
   • Suppressive therapy reduces recurrence rates by approximately 70-80% 2

4. For immunocompromised patients:

   • Higher doses may be required
   • For HIV-infected patients with CD4+ count ≥100 cells/mm³, higher doses of oral antivirals are necessary 1
   • Longer treatment duration until complete healing 1

Special Considerations

Renal Impairment

Dose adjustments are necessary based on creatinine clearance:

• For CrCl >25 mL/min: No adjustment needed
• For CrCl 10-25 mL/min: Reduce dose frequency (e.g., valacyclovir 500 mg every 24 hours)
• For CrCl <10 mL/min: Further reduction in dosing frequency 1

Resistant HSV Infections

• In immunocompromised patients with poor response to standard therapy, consider:
  • Increasing oral acyclovir to 800 mg five times daily
  • If no response after 5-7 days, obtain cultures for viral, fungal, and bacterial pathogens
  • Consider alternative agents like foscarnet (40 mg/kg three times daily) for confirmed resistant cases 7

Pain Management

• Topical anesthetics and sitz baths with warm water for genital lesions
• Viscous lidocaine 2% mouthwash for oral lesions
• Systemic analgesics for severe pain following WHO pain ladder 1

Patient Education and Counseling

• Instruct patients to:
  • Apply medication at first sign of prodrome
  • Wash hands before and after application
  • Continue treatment for full prescribed duration
  • Abstain from sexual activity during outbreaks or prodromal symptoms
  • Use condoms consistently to reduce transmission risk 1

Efficacy Considerations

• Early treatment initiation (within 24 hours of symptom onset) maximizes effectiveness 1, 5
• Valacyclovir has similar efficacy to acyclovir but with more convenient dosing 6
• For herpes labialis (cold sores), treatment reduces duration by approximately 1 day compared to placebo 2
• For genital herpes, treatment reduces median time to lesion healing from 6 days (placebo) to 4 days (valacyclovir) 2

By following these evidence-based treatment guidelines, HSV infections can be effectively managed to reduce symptom duration, decrease viral shedding, and improve quality of life for patients with recurrent disease.