HSV Prophylaxis for Lip Injections
For patients undergoing lip injections, prophylactic antiviral therapy with valacyclovir 500 mg twice daily starting the day before or the day of the procedure and continuing for 7-10 days is recommended to prevent HSV reactivation.
Risk Assessment and Rationale
Herpes simplex virus (HSV) reactivation is a recognized complication following facial procedures including lip injections with hyaluronic acid fillers. While rare, HSV reactivation can lead to:
- Increased mucosal damage
- Pain and swelling
- Delayed healing
- Potential scarring
- Secondary bacterial infections
The trauma from needle injections can trigger HSV reactivation in patients with latent infection, particularly in the perioral region where HSV-1 commonly establishes latency.
Prophylactic Regimen Options
First-line options:
- Valacyclovir: 500 mg twice daily, starting the day before or morning of procedure, continuing for 7-10 days 1
- Acyclovir: 400 mg three times daily, starting the day before or morning of procedure, continuing for 7-10 days 2
- Famciclovir: 250 mg twice daily, following similar timing as above
Patient Selection for Prophylaxis
Mandatory prophylaxis:
- Patients with history of recurrent herpes labialis
- Patients with prior HSV reactivation following cosmetic procedures
- Patients with frequent HSV outbreaks (≥3 per year)
Consider prophylaxis:
- HSV-seropositive patients without recent outbreaks
- Patients undergoing extensive lip augmentation
- Immunocompromised patients
Evidence Strength and Considerations
The recommendation for antiviral prophylaxis is supported by clinical evidence showing:
- Valacyclovir was 100% effective in preventing HSV reactivation when started either the day before or the day of facial resurfacing procedures 1
- Case reports document successful prevention of HSV reactivation with prophylactic antivirals in patients undergoing facial procedures 3, 4
Clinical Pearls and Pitfalls
- Timing matters: Starting prophylaxis before or on the day of the procedure is critical; starting after the procedure may be too late to prevent viral reactivation
- Duration: Continue for 7-10 days to cover the healing period when the risk of reactivation is highest
- Recognition: Early recognition of HSV reactivation (erythema, grouped vesicles, pain, tingling) is essential for prompt treatment
- Treatment dose: If breakthrough infection occurs despite prophylaxis, increase to treatment dosing (valacyclovir 1000 mg twice daily or acyclovir 800 mg 5 times daily)
- Avoid procedure: Consider postponing lip injections in patients with active herpes lesions until completely resolved
Special Populations
For immunocompromised patients (including those on immunosuppressive medications or with hematologic malignancies), consider:
- Longer duration of prophylaxis (10-14 days)
- Higher dosing (valacyclovir 1000 mg twice daily)
- More careful monitoring for breakthrough infections 5
By implementing appropriate antiviral prophylaxis, the risk of HSV reactivation following lip injections can be significantly reduced, improving patient outcomes and satisfaction with the cosmetic procedure.