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

Treatment of Herpes Simplex Virus (HSV) on the Face

The first-line treatment for HSV on the face is oral antiviral therapy with acyclovir 400 mg orally three times daily for 7-10 days, valacyclovir 1 g orally twice daily for 7-10 days, or famciclovir 250 mg orally three times daily for 7-10 days. 1

Medication Options

Oral Antivirals (Preferred)

• Acyclovir:
  • 400 mg three times daily for 7-10 days OR
  • 200 mg five times daily for 7-10 days 1
• Valacyclovir: 1 g twice daily for 7-10 days 1
• Famciclovir: 250 mg three times daily for 7-10 days 1

Topical Antivirals (For ocular involvement)

• Ganciclovir 0.15% gel: Apply 3-5 times daily 1
• Trifluridine 1% solution: Apply 5-8 times daily (not recommended for >2 weeks due to epithelial toxicity) 1

Treatment Algorithm

1. Initial presentation:

   • Begin oral antiviral therapy at the earliest sign of infection
   • Select one of the three recommended oral agents based on availability and patient factors
   • Treatment may be extended if healing is incomplete after 10 days 1

2. For HSV with ocular involvement:

   • Combine oral antivirals with topical ophthalmic antivirals
   • Avoid topical corticosteroids as they potentiate HSV infection 1
   • Schedule follow-up within one week consisting of interval history, visual acuity measurement, and slit-lamp biomicroscopy 1

3. For immunocompromised patients:

   • Consider higher doses of oral antivirals
   • For severe cases, initiate intravenous acyclovir 1
   • Monitor closely for treatment failure

4. For treatment-resistant cases:

   • If lesions do not begin to resolve within 7-10 days, suspect acyclovir resistance
   • Obtain viral culture and susceptibility testing
   • Consider alternative therapy with intravenous foscarnet (40 mg/kg three times daily) 1, 2

Special Considerations

Prevention

• Sunscreen (SPF 15 or above) can help prevent UV-triggered recurrences 3, 4
• For frequent recurrences, suppressive therapy may be considered:
  • Acyclovir 400 mg twice daily 3, 4
  • Valacyclovir 500-1000 mg once daily 3

Patient Education

• Advise abstaining from close contact when lesions are present
• Explain that the virus can be transmitted even during asymptomatic periods
• Encourage starting treatment at the first sign of prodrome for maximum effectiveness 3

Monitoring

• No routine laboratory monitoring is needed unless the patient has significant renal impairment 3
• For patients with ocular HSV, follow-up within one week is essential 1

Caveats and Pitfalls

1. Avoid topical corticosteroids with HSV epithelial infections as they can potentiate the infection and worsen outcomes 1

2. Do not delay treatment - efficacy is maximized when treatment is initiated during the prodromal phase or within 6 hours of first symptoms 5

3. Be vigilant for resistance in immunocompromised patients, who are more likely to develop antiviral-resistant HSV 2

4. Consider neonatal risk - explain the risk of neonatal infection to all patients, including men, and advise childbearing-aged women to inform healthcare providers during pregnancy 1

5. Don't undertreat - short-course therapy (1-3 days) should not be used in patients with HIV infection or other immunocompromising conditions 1

The most recent guidelines from the Ophthalmology journal (2024) and CDC recommendations provide clear evidence for the effectiveness of oral antiviral therapy in treating HSV infections on the face, with the goal of reducing symptom duration, accelerating healing, and preventing complications that could impact morbidity, mortality, and quality of life 1, 3.