What is the recommended treatment for herpes simplex?

Treatment of Herpes Simplex

For herpes simplex infections, oral acyclovir 200 mg five times daily for 7-10 days is the recommended first-line treatment for initial clinical episodes, while recurrent episodes can be treated with acyclovir 200 mg orally five times daily, 400 mg three times daily, or 800 mg twice daily for 5 days. 1

Treatment Recommendations by Clinical Scenario

First Clinical Episode of Genital Herpes

• Recommended regimen: Acyclovir 200 mg orally 5 times a day for 7-10 days or until clinical resolution 1
• Alternative options:
  • Acyclovir 400 mg orally three times daily for 7-10 days 2
  • Famciclovir 250 mg orally three times daily for 7-10 days 2

First Clinical Episode of Herpes Proctitis

• Recommended regimen: Acyclovir 400 mg orally 5 times a day for 10 days or until clinical resolution 1

Recurrent Episodes

• Treatment is most effective when started during the prodrome or within 2 days of lesion onset
• Recommended regimens:
  • Acyclovir 200 mg orally 5 times a day for 5 days, OR
  • Acyclovir 400 mg orally 3 times a day for 5 days, OR
  • Acyclovir 800 mg orally 2 times a day for 5 days 1
• A shorter 2-day course of acyclovir (800 mg three times daily) has also shown efficacy in reducing duration of lesions, episode length, and viral shedding 3

Daily Suppressive Therapy

• Indicated for patients with frequent recurrences (≥6 per year)
• Recommended regimen: Acyclovir 400 mg orally 2 times a day 1
• Alternative regimen: Acyclovir 200 mg orally 3-5 times a day 1
• Reduces frequency of HSV recurrences by at least 75%
• After 1 year of continuous therapy, discontinue to reassess recurrence rate

Severe Disease Requiring Hospitalization

• Recommended regimen: Acyclovir 5-10 mg/kg IV every 8 hours for 5-7 days or until clinical resolution 1, 4
• Indicated for disseminated infection including encephalitis, pneumonitis, or hepatitis

Special Populations

Immunocompromised Patients

• Higher doses and longer treatment durations are required 2
• Treatment should continue until complete healing of lesions 2
• For HIV-infected patients with CD4+ counts <200 cells/μL, higher oral doses may be necessary 2
• IV acyclovir is indicated for treatment of herpes simplex infections in immunocompromised patients 4

Acyclovir-Resistant HSV

• More common in immunocompromised patients
• Treatment options include:
  • Topical trifluridine (TFT) applied 3-4 times daily until complete healing
  • Intravenous foscarnet (40 mg/kg three times daily or 60 mg/kg twice daily) for 10 days
  • Consider cidofovir (intravenous or topical 1-3%) if foscarnet fails 5

Patient Education and Prevention

• Advise patients to:
  • Abstain from sexual activity while lesions are present 1
  • Use condoms during all sexual exposures 1
  • Be aware that asymptomatic viral shedding can lead to transmission 1
  • Apply medication at the first sign of prodrome if on episodic therapy 2
  • Remain in isolation until all lesions are completely crusted over if hospitalized 2

Symptomatic Relief

• Topical anesthetics
• Sitz baths with warm water
• Oral analgesics
• Keep lesions clean and dry 2

Common Pitfalls to Avoid

1. Delayed treatment: Antiviral therapy is most effective when started early in the course of an outbreak
2. Inadequate dosing: Immunocompromised patients require higher doses and longer treatment durations
3. Premature discontinuation: Treatment should continue until clinical resolution or complete crusting of lesions
4. Failure to counsel about transmission: Patients should understand that transmission can occur even during asymptomatic periods
5. Overlooking resistance: Consider acyclovir resistance in immunocompromised patients with poor response to standard therapy

The management of herpes simplex requires prompt initiation of antiviral therapy tailored to the clinical presentation, with special consideration for immunocompromised patients who may require more aggressive treatment approaches.