What is the recommended treatment for herpes?

Treatment Recommendations for Herpes

For herpes zoster (shingles), the recommended first-line treatment is valacyclovir 1 gram three times daily for 7 days, initiated at the earliest sign or symptom of herpes zoster. 1

Treatment Recommendations by Herpes Type

Herpes Zoster (Shingles)

• First-line treatment: Valacyclovir 1 gram three times daily for 7 days 1
• Alternative: Acyclovir 800 mg orally 5 times daily 2
• Treatment should be initiated within 48-72 hours of rash onset for maximum effectiveness 2, 1
• For severe or disseminated disease: IV acyclovir 10 mg/kg every 8 hours (hospitalization may be required) 2

Genital Herpes

1. Initial Episode:

   • Valacyclovir 1 gram twice daily for 10 days 1
   • Most effective when started within 48 hours of symptom onset 1

2. Recurrent Episodes:

   • Valacyclovir 500 mg twice daily for 3 days 1, 3
   • A 3-day course has been proven equivalent to a 5-day course in terms of lesion healing, pain duration, and episode length 3

3. Suppressive Therapy:

   • For patients with normal immune function: Valacyclovir 1 gram once daily 1
   • For patients with ≤9 recurrences per year: Valacyclovir 500 mg once daily 1
   • For HIV-infected patients (CD4+ count ≥100 cells/mm³): Valacyclovir 500 mg twice daily 1

Cold Sores (Herpes Labialis)

• Valacyclovir 2 grams twice daily for 1 day, taken 12 hours apart 1
• Initiate at earliest symptom (tingling, itching, or burning) 1

Dosage Adjustments

Renal Impairment

Acyclovir dosage adjustment based on creatinine clearance 2:

• 25 mL/min: 800 mg every 4 hours, 5 times a day

• 10-25 mL/min: 800 mg every 8 hours
• 0-10 mL/min: 800 mg every 12 hours

Special Populations

Pregnant Women

• Acyclovir 800 mg orally 5 times daily is recommended for herpes zoster during pregnancy 2
• Treatment is not associated with increased risk of major birth defects 2

Immunocompromised Patients

• May require longer treatment duration and closer monitoring 2
• For acyclovir-resistant herpes in immunocompromised patients:
  • Consider foscarnet 40 mg/kg three times daily or 60 mg/kg twice daily for 10 days 4
  • Topical trifluridine (TFT) may be used for accessible lesions 4

HIV-Infected Patients

• Higher doses of antiviral medication may be required, especially with CD4+ counts <200 cells/µL 2
• For suppressive therapy: Valacyclovir 500 mg twice daily 1

Pain Management

• Mild pain: Acetaminophen or NSAIDs 2
• Moderate to severe pain: Consider gabapentin (after obstetric consultation if pregnant) 2
• Topical options: Lidocaine patches for localized pain 2

Clinical Pearls and Pitfalls

Important Considerations

• Treatment is most effective when initiated within 72 hours of symptom onset 2, 1
• Valacyclovir has better bioavailability than acyclovir, allowing for less frequent dosing 5
• Suppressive therapy reduces outbreak frequency by 70-80% and decreases asymptomatic viral shedding 2

Common Pitfalls

• Delayed treatment initiation significantly reduces effectiveness
• Inadequate dosing in immunocompromised patients
• Failure to adjust dosage for renal impairment
• Not considering resistance in treatment-refractory cases, especially in immunocompromised patients

Follow-up Recommendations

• Schedule follow-up within 7 days to assess treatment response 2
• Monitor for complete resolution of lesions and evaluate for signs of dissemination or complications 2
• For recurrent genital herpes, consider suppressive therapy if experiencing ≥6 recurrences per year 1

Valacyclovir's simpler dosing regimen (compared to acyclovir's five-times-daily dosing) may improve patient adherence while maintaining equivalent efficacy 6, 5.