Treatment of Active HSV Infections with Liquid Acyclovir
For active herpes simplex virus (HSV) infections, oral acyclovir 200 mg 5 times daily for 7-10 days is the recommended treatment using liquid formulation. 1, 2
Dosing Recommendations for Different HSV Presentations
First Clinical Episode of Genital Herpes
- Acyclovir 200 mg orally 5 times a day for 7-10 days or until clinical resolution 1
- Treatment should be initiated as early as possible for maximum effectiveness 2
First Clinical Episode of Herpes Proctitis
- Acyclovir 400 mg orally 5 times a day for 10 days or until clinical resolution 1
Recurrent Episodes
- Acyclovir 200 mg orally 5 times a day for 5 days, or
- Acyclovir 400 mg orally 3 times a day for 5 days, or
- Acyclovir 800 mg orally 2 times a day for 5 days 1
- Treatment is most effective when initiated during the prodrome or within 2 days of lesion onset 2
Oral Herpes (Cold Sores)
- Same dosing options as recurrent genital episodes:
- Acyclovir 200 mg orally 5 times a day for 5 days
- Acyclovir 400 mg orally 3 times a day for 5 days
- Acyclovir 800 mg orally 2 times a day for 5 days 2
Special Populations
Immunocompromised Patients
- Higher doses may be required: acyclovir 400 mg orally 3-5 times daily until clinical resolution 3
- HIV-infected patients may require more aggressive therapy 1
- For acyclovir-resistant HSV (more common in immunocompromised patients), intravenous foscarnet is the treatment of choice 1, 4
- If poor response to standard oral acyclovir, increase dose to 800 mg five times daily 4
Pregnant Women
- Acyclovir is the antiviral drug with the most reported experience in pregnancy and appears to be safe 1
- Acyclovir is the first choice for therapy of HSV infections in pregnancy 1
Suppressive Therapy for Frequent Recurrences
- Daily suppressive therapy with acyclovir is recommended for persons with frequent or severe recurrences 1
- Suppressive therapy reduces frequency of HSV recurrences by at least 75% among patients with frequent recurrences 1
- After 1 year of continuous suppressive therapy, acyclovir should be discontinued to assess the patient's rate of recurrent episodes 1
Important Clinical Considerations
- Oral acyclovir is significantly more effective than topical formulations for treating HSV infections 2
- Acyclovir neither eradicates latent virus nor affects subsequent risk, frequency, or severity of recurrences after discontinuation 1, 2, 5
- Despite this limitation, acyclovir represents a major advance in HSV therapy 5
- The safety profile of acyclovir is favorable, with clinical trials showing similar safety profiles between acyclovir and placebo 6, 7
- Resistance to acyclovir remains rare in immunocompetent patients (<0.5%) but is more common in immunocompromised patients (approximately 5%) 6, 8
Common Pitfalls and Caveats
- Delayed initiation of therapy significantly reduces effectiveness; treatment should begin as early as possible 2
- Patients should be counseled about the natural history of HSV infection, including potential for recurrent episodes and asymptomatic viral shedding 3
- Sexual transmission can occur during asymptomatic periods; patients should use latex condoms during every act of sexual intercourse 1
- Patients should avoid sexual contact when herpetic lesions are evident 1