What is the recommended treatment for complications from facial Herpes Simplex Virus (HSV) outbreaks?

Treatment for Facial Herpes Simplex Virus (HSV) Outbreak Complications

For complications from facial HSV outbreaks, oral antiviral therapy (acyclovir, valacyclovir, or famciclovir) combined with appropriate topical treatments is recommended as first-line therapy, with specific management tailored to the type of complication. 1

First-Line Oral Antiviral Options

• Acyclovir: 400 mg five times daily for 7-10 days 1
• Valacyclovir: 1000 mg three times daily for 7 days 1
• Famciclovir: 500 mg three times daily for 7 days 1

Management Based on Specific Complications

Ocular Complications (HSV Conjunctivitis/Keratitis)

1. Topical antivirals:

   • Ganciclovir 0.15% gel three to five times per day 2
   • Trifluridine 1% solution five to eight times per day (not for >2 weeks due to epithelial toxicity) 2

2. Oral antivirals (in addition to topical treatment):

   • Acyclovir 200-400 mg five times daily
   • Valacyclovir 500 mg two to three times daily
   • Famciclovir 250 mg twice daily 2

3. Important cautions:

   • Avoid topical corticosteroids without antiviral coverage as they potentiate HSV infection 2
   • For HSV stromal keratitis, use topical steroids only in conjunction with oral antiviral therapy 2, 1

4. Follow-up: Schedule within 1 week of treatment initiation with visual acuity measurement and slit-lamp biomicroscopy 2

Cutaneous Complications

1. For resistant lesions:

   • Increase oral acyclovir to 800 mg five times daily 3
   • If no response after 5-7 days, consider alternative treatments:
     • Topical trifluridine applied 3-4 times daily for accessible lesions 3
     • Intravenous foscarnet (40 mg/kg three times daily or 60 mg/kg twice daily) for 10 days for resistant cases 3

2. Topical management:

   • White soft paraffin ointment applied every 2-4 hours to affected areas 1

Pain Management

• Mild pain: Acetaminophen or NSAIDs 1
• Moderate to severe pain: Consider gabapentin, pregabalin, or tricyclic antidepressants 1
• Localized pain: Lidocaine patches 1

Special Populations

Immunocompromised Patients

• May require longer duration of therapy and closer monitoring 1
• Higher risk of developing resistance to antivirals 3
• For severe cases, consider intravenous acyclovir 4
• For resistant cases, follow escalation protocol:
  1. High-dose oral acyclovir (800 mg five times daily)
  2. Intravenous foscarnet if oral therapy fails
  3. Consider cidofovir for foscarnet-resistant cases 3

Pregnant Patients

• Acyclovir is preferred due to established safety profile 1

Suppressive Therapy

Consider for patients with:

• Frequent recurrences (≥6 episodes per year)
• Severe or prolonged episodes
• Significant psychological distress from recurrences 1

Recommended regimens:

• Valacyclovir 500 mg twice daily
• Acyclovir 400 mg twice daily 1

Monitoring and Follow-up

• Schedule follow-up within 7 days to assess treatment response 1
• For ocular involvement, monitor for corneal subepithelial infiltrates which typically occur 1+ weeks after onset 2
• For patients on topical corticosteroids, regularly monitor IOP and pupillary dilation to evaluate for glaucoma and cataract 2
• Consider treatment failure if lesions don't begin to resolve within 7-10 days 1

Prevention

• Daily suppressive therapy reduces frequency of outbreaks by 70-80% 1
• After 1 year of continuous suppressive therapy, consider discontinuing to reassess recurrence rate 1

Clinical Pearls

• Valacyclovir appears somewhat more effective than famciclovir for suppression of HSV and associated viral shedding 5
• Topical trifluridine inevitably causes epithelial toxicity if used for more than 2 weeks; topical ganciclovir is less toxic to the ocular surface 2
• Neonates with HSV require prompt consultation with pediatrician as systemic HSV infection is life-threatening 2