Treatment of Herpes Simplex Virus (HSV) Scalp Infection

For HSV scalp infections, oral antiviral therapy with acyclovir 400 mg three times daily for 7-10 days is the recommended first-line treatment. 1

First-Line Treatment Options

For initial HSV scalp infection, the following oral antiviral medications are recommended:

Treatment may need to be extended if healing is incomplete after 10 days of therapy 1.

For recurrent HSV scalp infections, shorter treatment courses are effective:

For patients with frequent recurrences (≥6 episodes per year), daily suppressive therapy should be considered 2:

Acyclovir 400 mg orally twice daily 1
Famciclovir 250 mg orally twice daily 1
Valacyclovir 250 mg orally twice daily 1
Valacyclovir 500 mg orally once daily (less effective for very frequent recurrences) 1
Valacyclovir 1,000 mg orally once daily 1

Suppressive therapy reduces recurrence frequency by ≥75% in patients with frequent episodes 2.

For severe HSV scalp infections requiring hospitalization (disseminated infection or complications):

Acyclovir 5-10 mg/kg IV every 8 hours for 5-7 days or until clinical resolution 1

Higher doses of antivirals are recommended: acyclovir 400 mg orally 3-5 times daily until clinical resolution 1
For HIV-infected patients: famciclovir 500 mg twice daily has been effective in reducing recurrences and subclinical shedding 1
For severe cases: acyclovir 5 mg/kg IV every 8 hours may be required 1
If lesions persist despite treatment, suspect acyclovir resistance 1
For acyclovir-resistant strains: foscarnet 40 mg/kg IV every 8 hours until clinical resolution 1

Topical therapy with acyclovir is substantially less effective than systemic treatment and is not recommended 1
Treatment should be initiated as early as possible for optimal effectiveness, ideally within 72 hours of symptom onset 3
Suppressive treatment reduces but does not eliminate asymptomatic viral shedding 2
After 1 year of continuous suppressive therapy, consider discontinuation to assess recurrence frequency, which often decreases over time 2
Resistance to antiviral medications is rare in immunocompetent patients (<0.5%) but more common in immunocompromised patients (about 5%) 4
No laboratory monitoring is needed for patients receiving antiviral therapy unless they have significant renal impairment 2

Delaying treatment beyond 72 hours significantly reduces effectiveness 3
Using topical therapy alone, which has poor efficacy compared to systemic treatment 1
Failing to consider suppressive therapy in patients with frequent recurrences 2
Not recognizing potential acyclovir resistance in immunocompromised patients with persistent lesions despite appropriate therapy 5
Discontinuing immunosuppressive therapy prematurely in patients with inflammatory bowel disease who develop HSV infections 1