What is the recommended treatment for cold sore suppression?

Cold Sore Suppression Treatment

For cold sore suppression, daily oral valacyclovir 500 mg once daily is recommended as the first-line treatment for patients with frequent recurrences (≥4 episodes per year). 1, 2

Antiviral Options for Cold Sore Suppression

Recommended Regimens for Daily Suppressive Therapy:

• Valacyclovir 500 mg orally once daily (preferred for most patients) 1
• Valacyclovir 1000 mg orally once daily (alternative option) 1, 3
• Acyclovir 400 mg orally twice daily 1
• Famciclovir 250 mg orally twice daily 1

Efficacy of Suppressive Therapy

• Suppressive therapy reduces frequency of herpes recurrences by ≥75% among patients with frequent outbreaks 1
• Valacyclovir 500 mg daily has been shown to significantly increase the proportion of patients remaining recurrence-free over 4 months (60% vs 38% with placebo) 2
• Mean time to first recurrence is significantly longer with valacyclovir (13.1 weeks) compared to placebo (9.6 weeks) 2
• Suppressive therapy has been documented to be safe and effective for extended periods (up to 6 years with acyclovir and 1 year with valacyclovir and famciclovir) 1, 4

Comparing Suppressive vs. Episodic Therapy

Suppressive therapy has been shown to be more effective than episodic therapy for patients with frequent recurrences:

• Suppressive valacyclovir (1 g daily) results in fewer recurrences (0.30 per 120 days) compared to episodic therapy (0.71 per 120 days) 5
• Probability of remaining recurrence-free is significantly higher with suppressive therapy 5
• Pain severity is reduced by approximately 30-50% with suppressive therapy compared to episodic therapy 5

Patient Selection for Suppressive Therapy

Suppressive therapy should be considered for:

• Patients with ≥6 recurrences per year (primary candidates) 1
• Patients with ≥4 recurrences per year (also benefit from suppression) 2
• Patients experiencing significant psychological distress from recurrences 1

Episodic Treatment (When Suppression Is Not Indicated)

For patients with infrequent outbreaks who prefer episodic treatment:

• Valacyclovir 2 g twice daily for 1 day, initiated at the earliest symptom (tingling, itching, burning) 3, 6
• Acyclovir 400 mg orally three times daily for 5 days 1
• Famciclovir 125 mg orally twice daily for 5 days 1

Monitoring and Follow-up

• After 1 year of continuous suppressive therapy, consider discontinuation to reassess the frequency of recurrences, as frequency may decrease over time 1
• Safety monitoring has shown that long-term valacyclovir therapy (≤1000 mg/day) has a safety profile similar to placebo 4
• Suppressive therapy has not been associated with clinically significant acyclovir resistance among immunocompetent patients 1, 4

Important Considerations and Caveats

• Initiate treatment at the earliest sign of prodrome for maximum effectiveness in episodic therapy 1
• Valacyclovir has 3-5 times greater bioavailability than acyclovir, allowing for more convenient dosing regimens 6
• Valacyclovir 500 mg once daily may be less effective for patients with very frequent recurrences (≥10 episodes per year); these patients may require higher dosing 1
• While suppressive therapy reduces viral shedding, it does not completely eliminate it, so the risk of transmission is reduced but not eliminated 1
• Patient education about triggers and early recognition of prodromal symptoms is essential for optimal management 1