What is the recommended suppressive therapy regimen for frequent or severe cold sore (herpes simplex labialis) outbreaks?

Suppressive Therapy for Frequent or Severe Cold Sores

For patients with frequent or severe cold sore outbreaks, valacyclovir 500 mg once daily (which can be increased to 1000 mg once daily for very frequent recurrences) is recommended as first-line suppressive therapy. 1

Indications for Suppressive Therapy

• Suppressive therapy is indicated for patients experiencing six or more recurrences per year 1
• Patients with particularly severe, frequent, or complicated disease should be considered for suppressive therapy 1
• Significant psychological distress from recurrences is also an indication for suppressive therapy 1

First-Line Suppressive Therapy Options

• Valacyclovir 500 mg once daily (can increase to 1000 mg once daily for very frequent recurrences) 1
• Famciclovir 250 mg twice daily 1, 2
• Acyclovir 400 mg twice daily 1

Efficacy of Suppressive Therapy

• Daily suppressive therapy reduces the frequency of herpes recurrences by ≥75% among patients with frequent recurrences 1
• Suppressive therapy with oral valacyclovir has been shown to be more effective than episodic therapy in reducing frequency of recurrences (0.30 vs 0.71 recurrences per 120 days) and prolonging time to first recurrence 3
• The probability of remaining recurrence-free is significantly higher with suppressive therapy compared to episodic therapy 3

Duration of Therapy

• Safety and efficacy have been documented for acyclovir for up to 6 years 1
• Valacyclovir and famciclovir have documented safety for 1 year of continuous use 1
• After 1 year of continuous suppressive therapy, consider discontinuation to assess the patient's rate of recurrent episodes, as frequency decreases over time in many patients 1

Important Clinical Considerations

• Topical antivirals are not effective for suppressive therapy as they cannot reach the site of viral reactivation 1, 4
• Suppressive therapy reduces but does not eliminate asymptomatic viral shedding 1
• Dose adjustment may be required in patients with significant renal impairment 5
• For immunocompromised patients, higher doses or longer treatment durations may be required 5, 6

Common Pitfalls to Avoid

• Relying solely on topical treatments for suppression is ineffective 1, 5
• Failing to consider suppressive therapy in patients with frequent recurrences (≥6 per year) who could significantly benefit 1
• Not discussing potential triggers (e.g., UV light exposure, stress, fever) that patients should avoid even while on suppressive therapy 1
• Inadequate dosing, such as not using appropriate suppressive doses 5

Monitoring and Follow-up

• Regular assessment of therapy effectiveness and tolerability is recommended 1
• Consider a trial off therapy after 1 year to reassess recurrence frequency 1
• If recurrences return after stopping suppressive therapy, resuming the same regimen is appropriate 1