What is the treatment for oral herpes?

Treatment for Oral Herpes

For oral herpes (herpes labialis), the recommended treatment is oral antiviral therapy with acyclovir 400 mg orally five times daily for 5-7 days, valacyclovir 1g twice daily for 7-10 days, or famciclovir 250 mg three times daily for 5-7 days. 1

First-Line Treatment Options

Oral Antiviral Medications

• Acyclovir:

  • 400 mg orally five times daily for 5-7 days (first episode)
  • 200 mg orally five times daily for 5-7 days (alternative dosing)
  • 400 mg twice daily for suppressive therapy in frequent recurrences 1

• Valacyclovir:

  • 1g orally twice daily for 7-10 days 1
  • Better bioavailability than acyclovir, requiring less frequent dosing 2

• Famciclovir:

  • 250 mg orally three times daily for 5-7 days 1
  • Single-dose option: 1500 mg as a one-time dose (shown to reduce median time to healing to 4.4 days compared to 6.2 days with placebo) 3, 4

Treatment Timing and Efficacy

Starting treatment at the earliest sign of prodrome (tingling, burning, itching) maximizes efficacy 1. Antivirals should ideally be initiated within 24-48 hours of symptom onset, and no later than 72 hours for maximum benefit 1.

When comparing treatment options:

• Oral antivirals are substantially more effective than topical formulations 5
• Valacyclovir and famciclovir have better oral bioavailability than acyclovir, requiring less frequent dosing 2
• Single-dose famciclovir (1500 mg) has been shown to be effective for episodic treatment, offering convenience that may improve adherence 4

Special Populations

Immunocompromised Patients

• Higher doses or longer duration of treatment may be required:
  • Acyclovir 400 mg five times daily for 7-10 days 1
  • Consider IV acyclovir for severe cases 1
  • Monitor for signs of dissemination 2

Pregnant Patients

• Acyclovir 400 mg orally three times daily for 5-7 days is preferred due to its established safety profile (FDA pregnancy category B) 1

Management of Resistant Cases

If lesions do not begin to resolve within 7-10 days, consider treatment failure and possible resistance 1:

1. Obtain viral cultures for susceptibility testing
2. Consider alternative treatments:
   • Topical trifluridine (if lesions are accessible)
   • Intravenous foscarnet 40 mg/kg three times daily for resistant cases 1, 6

Supportive Measures and Prevention

• Keep the area clean and dry to prevent secondary bacterial infection 1
• Topical anesthetics may provide symptomatic relief during the vesicular phase 1
• Use sunscreen (SPF 15 or above) to prevent UV-triggered recurrences 1, 7
• Avoid known triggers including UV radiation, fever, psychological stress, and local trauma 1

Suppressive Therapy

For patients with frequent recurrences (≥6 episodes per year), consider suppressive therapy:

• Acyclovir 400 mg twice daily 1
• Valacyclovir 500-1000 mg once daily 7

Suppressive therapy can reduce recurrence rates by approximately 80% compared to placebo, significantly improving quality of life for patients with frequent outbreaks 7.