Acyclovir Dosing for Herpes Whitlow
For herpes whitlow treatment, oral acyclovir 200 mg five times daily for 10 days is recommended as the standard dosing regimen. 1
Dosing Options Based on Severity
Mild to Moderate Cases
- Oral acyclovir 200 mg five times daily for 10 days 1
- For patients with more than six recurrences per year, consider continuous suppressive therapy 1
Severe or Immunocompromised Cases
- Intravenous acyclovir for severe mucocutaneous HSV lesions 2
- Patients may be switched to oral therapy after lesions begin to regress 2
Dosage Adjustments for Renal Impairment
Acyclovir requires dose adjustment based on creatinine clearance:
| Creatinine Clearance (mL/min) | Dose 200 mg | Dose 400 mg | Dose 800 mg |
|---|---|---|---|
| >25 | 200 mg every 4 hours, 5 times a day | 400 mg every 12 hours | 800 mg every 4 hours, 5 times a day |
| 10-25 | 200 mg every 4 hours, 5 times a day | 400 mg every 12 hours | 800 mg every 8 hours |
| 0-10 | 200 mg every 12 hours | 200 mg every 12 hours | 800 mg every 12 hours |
Monitoring and Follow-up
- No laboratory monitoring needed unless patient has substantial renal impairment 2
- For high-dose IV acyclovir, monitor renal function at initiation and once or twice weekly 2
- Consider treatment failure if lesions do not begin to resolve within 7-10 days 2
- Schedule follow-up within 7 days to assess treatment response 2
Important Clinical Considerations
Treatment Efficacy
- With appropriate acyclovir dosing, healing is 50% faster and viral shedding stops 90% sooner 1
- Primary and recurrent herpetic whitlow respond well to acyclovir therapy 1, 3
Potential Pitfalls and Caveats
- Acyclovir therapy does not eliminate latent virus or prevent subsequent recurrences 4
- Acyclovir-resistant HSV should be suspected if lesions don't begin to resolve within 7-10 days 2
- Treatment of choice for resistant cases is IV foscarnet 2
- Most common adverse effects include nausea and headache 2
- Crystalluria and elevated serum creatinine can occur with bolus intravenous administration 4
Special Populations
- Acyclovir is the preferred agent during pregnancy due to its established safety profile 2
- Immunocompromised patients may require longer or more aggressive treatment courses 2
Recurrence Management
- For fewer than six recurrences per year: 200 mg acyclovir orally five times a day for 5 days at symptom onset 1
- For more than six recurrences per year: consider continuous suppressive oral acyclovir therapy 1
- After 1 year of continuous suppressive therapy, consider discontinuing to reassess recurrence rate 2