What are the recommended treatments for simple herpes simplex infections?

Treatment of Simple Herpes Simplex Infections

Oral antiviral medications including acyclovir, valacyclovir, and famciclovir are the recommended treatments for simple herpes simplex infections, with treatment regimens varying based on whether it's a first episode, recurrent episode, or suppressive therapy. 1

First Clinical Episode Treatment

• Acyclovir 200 mg orally 5 times a day for 7-10 days or until clinical resolution is attained 1
• Valacyclovir 1g orally twice daily for 7-10 days 2
• Famciclovir 250 mg orally three times daily for 7-10 days 2

Recurrent Episodes Treatment

• Acyclovir 400 mg orally three times daily for 5 days 1
• Valacyclovir 1000 mg orally twice daily for 1 day (short-course therapy) 1
• Famciclovir 1000 mg orally twice daily for 1 day (short-course therapy) 3

Suppressive Therapy (for frequent recurrences)

• Acyclovir 400 mg orally twice daily 4
• Valacyclovir 500 mg orally once daily (or 1000 mg once daily for patients with ≥10 episodes per year) 4
• Famciclovir 250 mg orally twice daily 4

Efficacy Considerations

• Daily suppressive therapy reduces the frequency of herpes recurrences by ≥75% among patients with frequent recurrences (six or more per year) 4
• Suppressive treatment reduces but does not eliminate asymptomatic viral shedding 4
• Valacyclovir appears to be somewhat better than famciclovir for suppression of genital herpes and associated viral shedding 5
• Acyclovir therapy remains effective and is often less expensive than newer options 6

Safety Profile

• The most common adverse events with acyclovir are nausea/vomiting (2.7%) and headache 7
• For famciclovir, the most common adverse events are headache and nausea 3
• Despite increasing use of HSV-specific antiviral agents, the incidence of resistant HSV-1 strains remains low (<0.5% in immunocompetent hosts) 1

Special Populations

HIV-Infected Patients

• Higher doses may be needed - acyclovir 400 mg orally three to five times daily until clinical resolution 2
• Intravenous foscarnet or cidofovir can be used to treat infection due to acyclovir-resistant isolates of HSV 1

Pregnant Women

• Acyclovir prophylaxis during late pregnancy is controversial and not routinely recommended 1
• For patients with frequent, severe recurrences of genital HSV disease, acyclovir prophylaxis might be indicated 1
• No pattern of adverse pregnancy outcomes has been reported after acyclovir exposures 1

Common Pitfalls and Considerations

• Early initiation of therapy is crucial for optimal effectiveness (within 72 hours of symptom onset) 2
• Antiviral medications neither eradicate latent virus nor affect the risk, frequency, or severity of recurrences after discontinuation 2
• After 1 year of continuous suppressive therapy, consider discontinuation to assess the patient's rate of recurrent episodes 4
• No laboratory monitoring is needed in patients receiving therapy unless they have substantial renal impairment 4
• Patients should be counseled about the natural history of HSV infection, with emphasis on potential for recurrent episodes and asymptomatic viral shedding 2

Prevention Strategies

• HIV-infected persons should use latex condoms during every act of sexual intercourse to reduce the risk for exposure to HSV 1
• Patients should specifically avoid sexual contact when herpetic lesions (genital or orolabial) are evident 1