What is the treatment for herpes simplex virus (HSV) burning?

Treatment for Herpes Simplex Virus (HSV) Burning

For symptomatic relief of HSV-related burning, initiate oral antiviral therapy immediately—valacyclovir 500 mg twice daily for 5 days is the preferred first-line treatment for recurrent episodes, with therapy most effective when started during prodromal symptoms (tingling, itching, burning) or within 1 day of lesion onset. 1

First-Line Antiviral Options for Acute Episodes

The CDC recommends several equivalent oral antiviral regimens for treating recurrent HSV episodes with burning symptoms 1:

• Valacyclovir 500 mg orally twice daily for 5 days (preferred for convenience) 1
• Acyclovir 400 mg orally three times daily for 5 days 1
• Acyclovir 800 mg orally twice daily for 5 days 1
• Famciclovir 125 mg orally twice daily for 5 days 1

For HIV-infected patients experiencing HSV burning, higher doses are required: valacyclovir or famciclovir 500 mg twice daily for 7 days, or acyclovir at increased dosing for 5-10 days 2, 3

Critical Timing Considerations

• Initiate treatment during the prodrome (when burning, tingling, or itching first appears) or within 24 hours of lesion onset for maximum effectiveness 1
• Treatment started beyond 6 hours after symptom onset has not been established as effective in clinical trials 3
• Early initiation significantly reduces symptom duration and viral shedding 1

Severe or Refractory Cases

For severe mucocutaneous HSV with intense burning that doesn't respond to oral therapy 2:

• IV acyclovir 5-10 mg/kg every 8 hours until lesions begin to regress 2
• Switch to oral therapy once improvement occurs and continue until complete healing 2
• Monitor renal function at initiation and once or twice weekly during IV treatment 2

Long-Term Suppressive Therapy

For patients with frequent recurrences (≥6 episodes per year) causing recurrent burning, daily suppressive therapy reduces recurrence frequency by ≥75% 1:

• Valacyclovir 500 mg orally once daily (for HIV-infected patients: 500 mg twice daily) 2, 1
• Acyclovir 400 mg orally twice daily 1
• Famciclovir 250 mg orally twice daily 1

Suppressive therapy is safe for up to 6 years with acyclovir and reduces asymptomatic viral shedding 1

Important Clinical Pitfalls

• Never use topical acyclovir—it is substantially less effective than oral therapy and will not adequately treat burning symptoms 1, 4
• Do not use short-course therapy (1-3 days) in HIV-infected patients—they require longer treatment courses 2
• Adjust doses for renal impairment—failure to do so can cause acute renal failure 3
• Do not delay treatment—waiting beyond the prodromal phase significantly reduces antiviral effectiveness 1

Treatment Resistance

If burning and lesions persist beyond 7-10 days of appropriate antiviral therapy, suspect drug resistance 2:

• Obtain viral culture with susceptibility testing 2
• IV foscarnet is the treatment of choice for acyclovir-resistant HSV 2
• Topical cidofovir or imiquimod may be used for external lesions, requiring 21-28 days of application 2

Renal Dosing Adjustments

For patients with creatinine clearance <40 mL/min, dose adjustments are mandatory 3:

• CrCl 20-39: Famciclovir 500 mg every 24 hours (for recurrent episodes) 3
• CrCl <20: Famciclovir 250 mg every 24 hours 3
• Hemodialysis: Administer dose following each dialysis session 3