What is the treatment for herpes labialis?

Treatment of Herpes Labialis (Cold Sores)

The first-line treatment for herpes labialis is oral valacyclovir 2g twice daily for 1 day, which should be initiated at the earliest symptoms for maximum effectiveness. 1

First-Line Treatment Options

• Oral antiviral medications are more effective than topical treatments for herpes labialis, reducing outbreak duration and associated pain by approximately 1 day 2
• Valacyclovir (2g twice daily for 1 day) is FDA-approved and recommended as first-line therapy due to its high bioavailability and convenient dosing 1, 2
• Famciclovir (1500mg as a single dose) is an effective alternative, significantly reducing time to healing compared to placebo (4.4 days vs 6.2 days) 3
• Treatment should be initiated within 24 hours of symptom onset, ideally during the prodromal stage (tingling, itching, burning) for maximum effectiveness 1, 2

Alternative Treatment Options

• Acyclovir (400mg five times daily for 5 days) is effective but requires more frequent dosing than newer agents 2
• Topical antivirals provide modest clinical benefit but are less effective than oral therapy 1, 4
• Topical 5% acyclovir cream/ointment can shorten lesion duration by about one day when applied early 5

Treatment Algorithm

1. First-line therapy: Oral valacyclovir 2g twice daily for 1 day 1, 2
2. Alternative oral options:
   • Famciclovir 1500mg as a single dose 3
   • Acyclovir 400mg five times daily for 5 days 2
3. For patients unable to take oral medication: Topical antivirals such as 5% acyclovir cream/ointment or 1% penciclovir cream 1, 4

Suppressive Therapy

• Chronic suppressive therapy should be considered for patients with severe or frequent recurrences (six or more episodes per year) 4
• Oral antiviral agents are the treatment of choice for suppressive therapy 4
• Topical agents are not effective for prophylaxis as they cannot reach the site of viral reactivation 1

Special Considerations

• Dose adjustment may be required in patients with significant renal impairment 1
• For immunocompromised patients, higher doses or longer treatment durations may be required 1
• Resistance to antiviral medications remains low (<0.5%) in immunocompetent hosts but may be higher in immunocompromised patients 6

Common Pitfalls to Avoid

• Relying solely on topical treatments when oral therapy is more effective 1
• Delayed initiation of therapy (beyond 24 hours of symptom onset) significantly reduces treatment efficacy 1, 2
• Inadequate dosing, such as not using short-course, high-dose therapy, which is more effective than traditional longer courses 1
• Failure to recognize that early treatment (during prodrome) may prevent lesion development entirely 6

Short-course, high-dose antiviral therapy offers greater convenience, cost benefits, and may improve patient adherence compared to traditional longer courses 1, 7