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

Best Treatment for Herpes Simplex Virus (HSV)

The Centers for Disease Control and Prevention (CDC) recommends oral acyclovir, valacyclovir, or famciclovir as first-line treatments for HSV infections, with specific dosing regimens based on whether it's a first episode, recurrent episode, or suppressive therapy. 1

First-Line Treatment Options

First Clinical Episode

• Acyclovir: 200 mg orally 5 times daily for 7-10 days 1
• Alternative regimens:
  • Acyclovir 400 mg orally 5 times daily for 10 days
  • Acyclovir 400 mg orally 3 times daily for 5 days
  • Acyclovir 800 mg orally 2 times daily for 5 days 1
  • Valacyclovir (more convenient dosing than acyclovir) 2

Recurrent Episodes

• Acyclovir: 400 mg orally 3 times daily for 5 days
• Alternative regimens:
  • Acyclovir 800 mg orally 2 times daily for 5 days
  • Acyclovir 800 mg orally 3 times daily for 2 days (shorter course option) 3

Suppressive Therapy (for frequent recurrences ≥6 per year)

• Acyclovir: 400 mg orally 2 times daily
• Alternative: Acyclovir 200 mg orally 3-5 times daily 1
• Suppressive therapy reduces recurrence frequency by at least 75% 1

Treatment Duration

• First episodes: 7-10 days
• Recurrent episodes: 5 days
• Continue treatment until all lesions have completely healed 1

Special Populations

Immunocompromised Patients

• Higher risk of severe disease and antiviral resistance
• May require longer treatment duration and closer monitoring 1
• For acyclovir-resistant HSV:
  • Foscarnet is indicated (40 mg/kg IV three times daily or 60 mg/kg twice daily) 4, 5
  • Cidofovir may be considered if foscarnet fails 5

Children (<45 kg)

• Acyclovir 20 mg/kg body weight (maximum 800 mg/dose) orally 4 times daily for 7-10 days 1

HIV-Infected Patients

• Higher oral doses may be required, especially with CD4+ counts <200 cells/μL 1

Dose Adjustment for Renal Impairment

• Dosage adjustment required based on creatinine clearance:

Creatinine Clearance (mL/min)	Acyclovir 200 mg	Acyclovir 400 mg	Acyclovir 800 mg
>25	Every 4h, 5x/day	Every 12h	Every 4h, 5x/day
10-25	Every 4h, 5x/day	Every 12h	Every 8h
0-10	Every 12h	Every 12h	Every 12h

Pain Management

• Mild pain: Acetaminophen or NSAIDs
• Moderate pain: Consider adding gabapentin or pregabalin
• Severe pain: Short-term opioid analgesics may be required
• Topical options: Lidocaine patches or capsaicin cream 1

Important Considerations

Efficacy Factors

• Early treatment initiation improves outcomes
• Valacyclovir has better bioavailability than acyclovir and allows for less frequent dosing (twice daily vs. five times daily) while maintaining equivalent efficacy 2
• Topical acyclovir is substantially less effective than oral therapy and is not recommended for most indications 1

Prevention Strategies

• Abstain from sexual activity while lesions are present
• Use condoms during all sexual exposures
• Inform sexual partners about HSV status 1

Common Pitfalls

1. Delayed treatment - decreases efficacy
2. Underdosing - can lead to treatment failure
3. Premature discontinuation - can lead to recurrence
4. Inadequate pain management - decreases quality of life
5. Failure to recognize resistance - particularly in immunocompromised patients 1

Treatment Algorithm

1. Assess patient status: First episode vs. recurrent vs. suppressive therapy need
2. Evaluate immune status: Immunocompetent vs. immunocompromised
3. Select appropriate regimen based on above factors
4. Adjust dose for renal impairment if needed
5. Monitor response and continue until complete healing
6. Consider suppressive therapy for patients with frequent recurrences