What is the treatment for herpes labialis?

Treatment for Herpes Labialis

Oral antiviral therapy is the most effective treatment for herpes labialis, with valacyclovir and famciclovir being superior options due to better bioavailability and less frequent dosing requirements compared to acyclovir. 1

First-Line Treatment Options

Oral Antivirals (Preferred)

• Valacyclovir: 1g twice daily for 7-10 days 1
• Famciclovir: 250mg three times daily for 5-7 days 1
• Acyclovir: 200mg 5 times daily for 5-7 days 1

Topical Antivirals (Less Effective)

• Penciclovir cream (Denavir): Apply every 2 hours while awake for 4 days, starting within 1 hour of symptom onset 2
• Acyclovir cream/ointment (5%): Apply 5 times daily 3

Treatment Timing and Efficacy

• Treatment should be initiated within 48 hours of symptom onset, ideally during the prodromal stage 1, 4
• Earlier treatment (within 24-48 hours) correlates with significantly better outcomes 1
• Oral antivirals shorten lesion duration by approximately half a day and reduce pain duration 4
• Topical penciclovir shortens lesion duration by approximately half a day compared to placebo 2

Treatment Algorithm

1. Assess timing: If within 48 hours of symptom onset, proceed with treatment
2. Assess patient factors:
   • For immunocompetent adults: Use oral antivirals (preferably valacyclovir or famciclovir)
   • For pregnant patients: Acyclovir 400mg three times daily for 5-7 days 1
   • For immunocompromised patients: Higher doses of antivirals for 7-10 days 1
3. Monitor response: Improvement expected within 7-10 days of treatment initiation 1

Special Considerations

Frequent Recurrences

• For patients with ≥6 episodes per year, consider suppressive therapy with:
  • Acyclovir: 400mg twice daily 1, 4
  • Valacyclovir or famciclovir (better bioavailability but more expensive) 4

Prevention Strategies

• Apply sunscreen (SPF 15+) to prevent UV-triggered recurrences 1, 5
• Avoid known triggers: UV radiation, fever, psychological stress, local trauma 1
• Keep the area clean and dry to prevent secondary infection 1

Treatment Pitfalls to Avoid

• Delayed initiation: Starting treatment after 48 hours significantly reduces efficacy 4, 6
• Inadequate dosing: Lower doses are less effective; follow recommended dosing regimens 1
• Relying solely on topical agents: Oral antivirals are superior to topical therapy for most patients 4
• Ignoring resistance: Consider resistance if lesions don't begin to resolve within 7-10 days 1

Medication Selection Considerations

• Valacyclovir and famciclovir have better oral bioavailability than acyclovir, requiring less frequent dosing 1
• Newer high-dose, 1-day regimens using famciclovir or valacyclovir offer greater convenience and cost-effectiveness compared to traditional 5-7 day therapy 6
• Topical agents are less effective but may be appropriate for mild cases or when oral therapy is contraindicated 4

Remember that treatment efficacy is significantly enhanced when initiated during the prodromal phase, before visible lesions appear 3, 7.