Treatment for HSV-1 Infection: Initial and Recurrent Episodes
For HSV-1 infections, oral antiviral medications including valacyclovir, acyclovir, and famciclovir are the mainstay of treatment, with different regimens recommended for initial versus recurrent episodes. 1
Initial Episode Treatment
For first clinical episodes of HSV-1 infection, longer treatment courses are recommended 2:
Treatment may be extended if healing is incomplete after 10 days of therapy 2
Higher dosages of acyclovir (400 mg orally five times a day) may be used for first-episode oral infections, including stomatitis or pharyngitis 2
Recurrent Episode Treatment
For recurrent episodes, shorter treatment courses are recommended 2:
Treatment is most effective when started during the prodromal period or within 1 day after onset of lesions 2, 3
Patients should be provided with medication or a prescription to initiate treatment at the first sign of prodrome or lesions 2
Delayed treatment beyond 72 hours significantly reduces effectiveness 3
Suppressive Therapy
Daily suppressive therapy should be considered for patients with frequent recurrences (≥6 episodes per year) 2, 1
Recommended suppressive regimens include 2:
Suppressive therapy reduces the frequency of genital herpes recurrences by ≥75% among patients with frequent recurrences 2
After 1 year of continuous suppressive therapy, discontinuation should be considered to assess the patient's recurrence rate 2
Important Clinical Considerations
Topical acyclovir is substantially less effective than systemic therapy and is not recommended 1, 4
Systemic antiviral drugs partially control symptoms but do not eradicate latent virus or affect subsequent recurrences after discontinuation 2, 1
HSV-1 causes 5-30% of first-episode genital herpes cases, but clinical recurrences are much less frequent for HSV-1 than HSV-2 genital infection 2
Patient counseling is essential and should include information about 2:
- Natural history of HSV infection
- Potential for recurrent episodes and asymptomatic viral shedding
- Sexual transmission risk
- Methods to reduce transmission (abstaining during outbreaks, condom use)
Special Populations
HIV-infected patients with HSV should be monitored closely as they may require longer courses of therapy than HIV-negative patients 2, 1
For immunocompromised patients, higher doses or longer courses of antivirals may be needed 5
For pregnant women, safety considerations are important - ciprofloxacin is contraindicated during pregnancy 2
For severe disease or complications requiring hospitalization, intravenous therapy may be necessary 5
Treatment Failure Considerations
If symptoms persist beyond expected healing time, consider incorrect diagnosis, co-infection with another STD, HIV infection, poor medication adherence, or antiviral resistance 1
For acyclovir-resistant HSV, which is rare in immunocompetent patients but more common in immunocompromised hosts, IV foscarnet is the treatment of choice 6