What are the treatment options for oral herpes?

Treatment Options for Oral Herpes

Oral antiviral therapy, particularly valacyclovir 2g twice daily for 1 day, is the most effective treatment for oral herpes (cold sores), especially when started at the first sign of symptoms. 1

First-Line Treatment: Oral Antivirals

Oral antiviral medications are the cornerstone of treatment for oral herpes, with several options available:

1. Valacyclovir (Preferred):

   • Primary regimen: 2g twice daily for 1 day
   • Alternative regimen: 2g twice daily on day 1, then 1g twice daily on day 2 1

2. Famciclovir:

   • 1500mg as a single dose OR
   • 750mg twice daily for 1 day 1
   • Note: FDA-approved for treatment of recurrent episodes of orolabial herpes in both immunocompetent and HIV-infected adults 2

3. Acyclovir:

   • 800mg 5 times daily for 5-7 days 1
   • Less commonly recommended due to frequent dosing requirements

Treatment Based on Disease Stage

Prodromal Stage

• Immediate initiation of oral antiviral therapy (valacyclovir or famciclovir) is crucial
• Docosanol can be used as an alternative if oral medication is unavailable 1

Vesicular Stage

• Continue oral antiviral therapy if started early
• Avoid touching or breaking blisters 1

Crusting Stage

• Continue antiviral therapy if started early
• Focus on moisturizing with white soft paraffin
• Keep the area clean to prevent secondary infection 1

Healing Stage

• Continue moisturizing until completely healed
• Protect skin from sun exposure with SPF 15+ 1

Topical Treatment Options

• Acyclovir 5% cream: Apply 5 times daily for 4 days (modest effect on healing time) 1
• Pain relief options:
  • Mixture of Maalox and diphenhydramine
  • Viscous lidocaine (use with caution in young children)
  • Benzydamine hydrochloride oral rinse/spray every 3 hours 1

Symptomatic Relief and Complication Prevention

• Maintain moisture: Apply white soft paraffin ointment to lips every 2 hours to prevent cracking and bleeding 1
• Prevent secondary infection: Use antiseptic oral rinse (0.2% chlorhexidine) twice daily 1
• Hydration: Encourage fluid intake; consider IV fluids if oral intake is severely compromised 1
• Nutrition: Consume soft, non-acidic foods; cold foods/beverages may provide comfort 1
• Pain management: Use analgesics ranging from acetaminophen to opioids based on pain severity 1

Special Populations

Pregnant Patients

• Acyclovir: 400mg orally three times daily for 5-7 days OR 200mg orally five times daily for 5-7 days 1
• Acyclovir has an established safety profile in pregnancy

Immunocompromised Patients

• Higher doses: Acyclovir 400mg five times daily for 7-10 days 1
• Severe cases: IV acyclovir 5-10mg/kg every 8 hours until lesions heal 1
• Consider prophylactic antiviral therapy to reduce recurrence risk 1

Treatment-Resistant Cases

For patients who fail standard therapy (particularly immunocompromised individuals):

1. Increase oral acyclovir to 800mg five times daily
2. If no response after 5-7 days, consider:
   • Topical trifluridine (TFT) applied 3-4 times daily until healed
   • Intravenous foscarnet 40mg/kg three times daily or 60mg/kg twice daily for 10 days 1, 3

Prevention Strategies

• Avoid known triggers: UV radiation, fever, psychological stress, local trauma 1
• Use sunscreen (SPF 15+) to prevent UV-triggered recurrences 1
• Keep the area clean and dry to prevent secondary infection 1

Follow-up Recommendations

Follow-up is necessary if:

• Symptoms worsen
• No improvement after 72 hours of treatment
• New symptoms develop
• Patient is immunocompromised 1

Treatment response should be monitored, with improvement expected within 7-10 days. If lesions don't begin to resolve within this timeframe, consider treatment failure and possible resistance 1.