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

Treatment of Herpes Simplex Virus (HSV) 1

For HSV-1 infections, the recommended treatment includes oral antiviral medications such as acyclovir, valacyclovir, or famciclovir, which should be initiated at the first sign of symptoms to effectively reduce duration and severity of outbreaks. 1

First Clinical Episode Treatment

• For first clinical episodes of HSV-1, recommended regimens include:

  • Acyclovir 400 mg orally three times a day for 7-10 days 1
  • Acyclovir 200 mg orally five times a day for 7-10 days 1
  • Famciclovir 250 mg orally three times a day for 7-10 days 1
  • Valacyclovir 1 g orally twice a day for 7-10 days 1

• Treatment may be extended if healing is incomplete after 10 days of therapy 1

• For herpes proctitis or oral infection (stomatitis/pharyngitis), higher dosages of acyclovir (400 mg orally five times a day) may be required 1

Recurrent Episodes Treatment

• For recurrent episodes, treatment options include:

  • Acyclovir 400 mg orally three times a day for 5 days 1
  • Acyclovir 800 mg orally twice daily for 5 days 1
  • Acyclovir 800 mg orally three times a day for 2 days 1
  • Famciclovir 1500 mg as a single dose or 750 mg twice daily for 1 day 1
  • Valacyclovir 2 g twice daily for 1 day 1

• Treatment should be initiated at the first sign of prodrome or within 1 day of lesion onset for maximum effectiveness 1, 2

Suppressive Therapy

• For patients with frequent recurrences (≥6 per year), suppressive therapy is recommended: 1

  • Acyclovir 400 mg orally twice daily 1, 2
  • Valacyclovir 500 mg once daily 1, 2
  • Valacyclovir 1 g once daily for patients with ≥10 recurrences per year 1

• Suppressive therapy reduces frequency of recurrences by ≥75% and reduces asymptomatic viral shedding 1

• Safety has been documented for acyclovir for up to 6 years and valacyclovir/famciclovir for 1 year 1

Special Populations

• For immunocompromised patients:

  • Longer courses of therapy are often required 1, 3
  • Closer monitoring is necessary as healing may be slower 1, 3
  • Higher doses may be needed for patients with apparent resistance to standard therapy 3, 4

• For pediatric patients:

  • Valacyclovir is indicated for cold sores in patients ≥12 years 5
  • Dosing should be adjusted based on age and weight 5

Important Clinical Considerations

• Topical acyclovir is substantially less effective than oral therapy and is not recommended 1, 3

• Antiviral medications do not eradicate latent virus or affect the risk, frequency, or severity of recurrences after treatment is discontinued 1

• Early treatment (during prodrome) provides the best outcomes and may abort the episode in some patients 6, 2

• For herpes labialis (cold sores), single-day high-dose therapy has shown effectiveness in reducing healing time 1

• For acyclovir-resistant HSV (primarily in immunocompromised patients), alternatives include foscarnet (40 mg/kg IV three times daily) or cidofovir 4, 7

• Patient education about the natural history of HSV infection, potential for recurrent episodes, asymptomatic viral shedding, and methods to reduce transmission is an essential component of management 1