What is the treatment for cold sores?

Treatment of Cold Sores

Oral antiviral medications, particularly valacyclovir 2g twice daily for 1 day, are the most effective first-line treatment for cold sores, reducing outbreak duration by approximately 1 day when initiated early. 1, 2

First-Line Treatment Options

• Valacyclovir 2g twice daily for 1 day is the preferred treatment for cold sores due to its high bioavailability, convenient dosing, and FDA approval 1, 3
• Famciclovir 1500mg as a single dose is an effective alternative that significantly reduces healing time of primary lesions 1, 4
• Acyclovir 400mg five times daily for 5 days is another option but requires more frequent dosing 2, 5

Treatment Timing and Efficacy

• Treatment should be initiated within 24 hours of symptom onset, ideally during the prodromal stage (itching, burning) for maximum effectiveness 1, 2
• Early initiation is critical as peak viral titers occur in the first 24 hours after lesion onset 6
• The efficacy of treatment initiated after the development of clinical signs (papule, vesicle, or ulcer) has not been established 3
• Short-course, high-dose regimens offer greater convenience, cost benefits, and may improve patient adherence 1, 7

Management for Frequent Recurrences

• Consider suppressive therapy for patients experiencing six or more recurrences per year 1, 6
• Suppressive therapy options include:
  • Valacyclovir 500mg once daily (can increase to 1000mg once daily for very frequent recurrences) 1
  • Famciclovir 250mg twice daily 1
  • Acyclovir 400mg twice daily 1, 6
• Daily suppressive therapy reduces the frequency of herpes recurrences by ≥75% among patients with frequent recurrences 1
• Safety and efficacy have been documented for acyclovir for up to 6 years, and for valacyclovir and famciclovir for 1 year of continuous use 1

Special Populations

• For children ≥12 years, valacyclovir 2g twice daily for 1 day is recommended 6, 3
• For children <12 years, valacyclovir is not FDA-approved for cold sores 3
• For pregnant women, valacyclovir has shown no increased risk of major birth defects during first-trimester exposure (4.5%, 95% CI: 0.24% to 24.9%) 3

Common Pitfalls to Avoid

• Relying solely on topical treatments when oral therapy is more effective 1, 2
• Starting treatment too late, as efficacy decreases significantly when treatment is initiated after lesions have fully developed 1, 6
• Using topical antivirals for suppressive therapy, which is ineffective since they cannot reach the site of viral reactivation 1, 6
• Failing to consider suppressive therapy in patients with frequent recurrences who could significantly benefit 1

Preventive Measures

• Identify and avoid personal triggers (stress, fever, sunlight exposure) 6
• Despite concerns, the development of resistance to oral antiviral agents when used episodically in immunocompetent patients is unlikely to occur (<0.5%) 8, 6

Treatment Evolution

• Recent trends show increasing use of valacyclovir and decreasing use of acyclovir, suggesting physicians are evolving their treatment strategies to implement newer antiviral medications with more convenient dosing 5
• High-dose, short-duration valacyclovir therapy (2g twice daily for 1 day) has been shown to be both safe and effective, offering patients a unique and convenient dosing alternative compared to available topical therapies 7