What is the treatment for recurrent Herpes Simplex Virus (HSV) 1?

Treatment of Recurrent HSV-1 Infections

Valacyclovir 500 mg twice daily is the recommended first-line treatment for recurrent HSV-1 infections, with 1000 mg once daily being an equally effective alternative for improved adherence. 1, 2

First-Line Treatment Options

Episodic Treatment

For episodic treatment of recurrent HSV-1 (cold sores/herpes labialis):

• Valacyclovir:

  • 2 grams twice daily for 1 day 1
  • Most effective when started within 2 hours of symptom onset

• Famciclovir:

  • 1500 mg as a single dose 3

Suppressive Therapy

For patients with frequent recurrences (≥6 episodes per year):

• Valacyclovir:

  • 500 mg once daily (for patients with <10 recurrences per year) 4
  • 1000 mg once daily (for patients with ≥10 recurrences per year) 4

• Famciclovir:

  • 250 mg twice daily 3

Treatment Duration

• Episodic treatment: Complete the prescribed regimen (1-3 days depending on medication and dosing)
• Suppressive therapy: Continuous daily therapy; consider reassessing after 12 months of therapy 1

Treatment Selection Algorithm

1. Determine recurrence frequency:

   • <6 episodes per year: Episodic treatment
   • ≥6 episodes per year: Consider suppressive therapy

2. For episodic treatment:

   • Prioritize early initiation (within first 2 hours of prodromal symptoms)
   • Choose between single-day high-dose regimen or multi-day regimen based on patient preference

3. For suppressive therapy:

   • Select dose based on recurrence frequency
   • Consider once-daily regimens to improve adherence

Special Populations

Immunocompromised Patients (including HIV)

• Valacyclovir: 500 mg twice daily for 5-7 days for episodic treatment 1
• Famciclovir: 500 mg twice daily for 7 days for recurrent episodes 3

Patients with Renal Impairment

Dose adjustment required based on creatinine clearance:

• For valacyclovir and famciclovir, reduce dose according to creatinine clearance 3

Evidence Quality and Considerations

The evidence supporting valacyclovir for HSV-1 treatment is robust. Clinical trials have demonstrated that:

• Valacyclovir 1000 mg once daily is equivalent to 500 mg twice daily for episodic treatment 5
• A 3-day course is as effective as a 5-day course for episodic treatment 6
• Valacyclovir has superior bioavailability compared to acyclovir, allowing for less frequent dosing 7

Common Pitfalls to Avoid

1. Delayed initiation: Treatment efficacy decreases significantly when started after lesions appear. Educate patients to begin treatment during the prodromal phase.

2. Inadequate duration: Complete the full prescribed course even if symptoms improve.

3. Overlooking triggers: Advise patients to use sunscreen (SPF 15+) to prevent UV-triggered recurrences 2

4. Inappropriate expectations: Inform patients that treatment reduces duration and severity but does not cure HSV infection.

5. Neglecting prevention: For patients with frequent recurrences, suppressive therapy is more effective than episodic treatment for quality of life improvement.