What treatment options are available for a persistent herpes simplex virus (HSV) bump?

Treatment Options for Persistent HSV Bump

Valacyclovir 500 mg twice daily for 5 days is the most effective treatment for a persistent herpes simplex virus (HSV) bump that won't go away. 1

First-Line Treatment Options

Oral Antiviral Therapy

• Valacyclovir (preferred):

  • 500 mg twice daily for 5 days for recurrent episodes 1
  • Offers better bioavailability than acyclovir, requiring less frequent dosing 2
  • Median time to lesion healing is 4 days (versus 6 days with placebo) 1

• Acyclovir (alternative):

  • 800 mg 5 times daily for 5-7 days 3
  • Dosage adjustment required for renal impairment 3

Topical Options

• Penciclovir 1% cream: Apply every 2 hours while awake for 4 days 4
  • Limited systemic absorption makes it suitable for localized lesions 4
  • Works through inhibition of HSV polymerase 4

For Persistent Lesions (Not Responding to Initial Treatment)

If the lesion doesn't respond to standard therapy after 7-10 days, consider:

1. Obtain viral culture and susceptibility testing to check for acyclovir-resistant HSV 3

2. Treatment escalation protocol:

   • Increase oral acyclovir to 800 mg five times daily 5
   • If no response after 5-7 days, consider alternative therapies 5

3. For accessible lesions with suspected resistance:

   • Apply trifluridine (TFT) ophthalmic solution topically 3-4 times daily until complete healing 5

4. For inaccessible lesions or poor response to topical therapy:

   • Consider intravenous foscarnet (40 mg/kg three times daily or 60 mg/kg twice daily) for 10 days 5

Suppressive Therapy for Frequent Recurrences

If this is a recurrent issue (≥6 outbreaks per year), consider long-term suppressive therapy:

• For patients with <10 recurrences per year:

  • Valacyclovir 500 mg once daily 6
  • Reduces recurrence rates by up to 55% at 6 months 1

• For patients with ≥10 recurrences per year:

  • Valacyclovir 1 gram once daily or 250 mg twice daily 6
  • Acyclovir 400 mg twice daily (alternative) 6

Special Considerations

• Immunocompromised patients may require longer treatment duration and closer monitoring 3
• Pregnant patients can safely use acyclovir due to its established safety profile 3
• Breastfeeding: Valacyclovir is present in breast milk but provides minimal exposure to the infant (approximately 0.6 mg/kg/day) 1

Follow-up Recommendations

• Schedule follow-up within 7 days to assess treatment response 3
• Monitor for complete resolution of lesions 3
• If lesions don't begin to resolve within 7-10 days, suspect treatment failure and consider viral resistance 3

Remember that persistent HSV lesions in immunocompetent individuals are uncommon, and failure to respond to appropriate antiviral therapy should prompt consideration of alternative diagnoses or antiviral resistance.