What are the treatment options for herpes?

Treatment Options for Herpes

For herpes simplex virus infections, the first-line treatment is oral antiviral therapy with valacyclovir, acyclovir, or famciclovir, with specific regimens depending on the type of infection (genital, labial) and whether it's an initial episode, recurrent episode, or suppressive therapy. 1

Types of Herpes and First-Line Treatments

Herpes Simplex (HSV-1 and HSV-2)

• Oral/Labial Herpes (Cold Sores):

  • First episode or recurrent episode:
    • Valacyclovir: 2 grams twice daily for 1 day 2
    • Famciclovir: 1500 mg as a single dose 3
    • Acyclovir: 800 mg five times daily for 5 days 1

• Genital Herpes:

  • Initial episode:

    • Valacyclovir: 1 gram twice daily for 10 days 2
    • Acyclovir: 800 mg five times daily for 7-10 days 1
    • Famciclovir: Not FDA approved for first episodes 3

  • Recurrent episodes:

    • Valacyclovir: 500 mg twice daily for 3-5 days 2
    • Famciclovir: 1000 mg twice daily for 1 day 3
    • Acyclovir: 800 mg five times daily for 5 days 1

  • Suppressive therapy:

    • Valacyclovir: 1 gram once daily (for ≥10 recurrences/year) or 500 mg once daily (for <10 recurrences/year) 2, 4
    • Famciclovir: 250 mg twice daily 3
    • Acyclovir: 800 mg twice daily 1

Herpes Zoster (Shingles)

• Valacyclovir: 1 gram three times daily for 7 days 1
• Famciclovir: 500 mg every 8 hours for 7 days 3
• Acyclovir: 800 mg five times daily for 7-10 days 1

Comparative Efficacy

• Valacyclovir appears somewhat more effective than famciclovir for suppression of genital herpes and viral shedding 5
• For herpes zoster, valacyclovir is more effective than acyclovir in reducing pain and postherpetic neuralgia 6
• Valacyclovir is the only antiviral FDA-approved for once-daily suppressive therapy for genital herpes and for a 3-day regimen of episodic treatment 6

Special Populations

HIV-Infected Patients

• Recurrent orolabial or genital herpes:
  • Famciclovir: 500 mg twice daily for 7 days 3
  • Valacyclovir: 500 mg twice daily for 5-10 days 1, 2

Renal Impairment

• Dosage adjustments required based on creatinine clearance:

  Acyclovir (800 mg dose):

  Creatinine Clearance (mL/min)	Dose Adjustment
  >25	800 mg every 4 hours, 5x daily
  10-25	800 mg every 8 hours
  0-10	800 mg every 12 hours

  Valacyclovir:

  Creatinine Clearance (mL/min)	Dose Adjustment
  ≥50	No adjustment needed
  30-49	No adjustment needed
  10-29	500 mg every 24 hours
  <10	500 mg every 24 hours

Adjunctive Treatments for Symptom Management

• Pain management:
  • Topical anesthetics (e.g., lidocaine 2% for oral lesions)
  • Oral analgesics following WHO pain management ladder
  • Sitz baths with warm water for genital lesions
  • Keeping lesions clean and dry 1

Prevention of Transmission

• Suppressive antiviral therapy reduces the risk of HSV transmission to sexual partners 2
• Patients should abstain from sexual activity while lesions are present
• Condom use during all sexual exposures is recommended
• Patients should be educated about asymptomatic viral shedding 1

Important Clinical Considerations

• Treatment efficacy is maximized when started within 48-72 hours of symptom onset 1
• Suppressive therapy reduces recurrence frequency by 70-80% 1
• For pregnant women with genital herpes, healthcare providers should be informed 1
• Elderly patients may require dose adjustment due to age-related changes in renal function 1

Valacyclovir and famciclovir have better bioavailability and less frequent dosing requirements than acyclovir, which may improve patient adherence to therapy 6, 7.