What is the recommended treatment for simplex lesions?

Treatment of Herpes Simplex Lesions

For herpes simplex lesions, the recommended treatment is antiviral therapy with topical ganciclovir 0.15% gel three to five times per day or trifluridine 1% solution five to eight times per day, or oral antivirals such as acyclovir, valacyclovir, or famciclovir. 1

Topical Antiviral Treatment Options

• Ganciclovir 0.15% gel applied three to five times daily is preferred for topical treatment due to less ocular surface toxicity compared to trifluridine 1
• Trifluridine 1% solution applied five to eight times daily is an alternative but can cause epithelial toxicity if used for more than 2 weeks 1

Oral Antiviral Treatment Options

• Acyclovir: 200-400 mg five times daily 1
• Valacyclovir: 500 mg two or three times daily 1
• Famciclovir: 250 mg twice daily 1

Treatment Algorithm

For Herpes Simplex Conjunctivitis/Blepharoconjunctivitis

1. First-line therapy: Initiate treatment with topical antivirals (ganciclovir 0.15% gel or trifluridine 1% solution) 1
2. For inadequate response: Add oral antiviral therapy, as topical treatment alone may not prevent progression 1
3. Follow-up: Schedule a visit within 1 week of treatment initiation to assess response 1

For Herpes Simplex Keratitis (with corneal involvement)

1. First-line therapy: Combination of topical and oral antiviral therapy 1
2. Dosing: Higher doses of oral antivirals may be effective in cases showing resistance to standard therapy 1

Important Considerations

• Avoid topical corticosteroids: Topical corticosteroids potentiate HSV epithelial infections and should be avoided in herpes simplex lesions 1
• Duration of therapy: For acute infections, treatment typically continues for 7-10 days 1
• Neonatal cases: Require prompt consultation with pediatrician or primary care physician as systemic HSV infection is life-threatening 1
• Recurrent disease: Lower doses of oral antivirals may be considered for long-term prophylaxis against recurrent HSV conjunctivitis and keratitis 1

Monitoring and Follow-up

• All patients should have a follow-up visit within 1 week of treatment initiation 1
• Follow-up should include:
  • Interval history
  • Visual acuity measurement
  • Slit-lamp biomicroscopy 1

Special Populations

Immunocompromised Patients

• May require more aggressive therapy and longer treatment duration 1
• Infections caused by acyclovir-resistant strains require alternative antiviral agents 1

Neonates

• Require higher doses of acyclovir (20 mg/kg intravenously every 8 hours) 1
• Prompt consultation with pediatrician is essential as systemic HSV infection is life-threatening 1

Treatment Pitfalls to Avoid

• Delaying treatment initiation (early treatment leads to better outcomes) 1
• Using topical corticosteroids without antiviral coverage (can potentiate HSV infection) 1
• Discontinuing topical trifluridine too late (can cause epithelial toxicity if used >2 weeks) 1
• Inadequate follow-up (patients should be reassessed within 1 week) 1