What is the treatment for herpes labialis?

Treatment of Herpes Labialis

For episodic treatment of herpes labialis, oral valacyclovir 2g twice daily for 1 day is the first-line therapy, initiated at the earliest sign of prodromal symptoms or within 24 hours of lesion onset. 1, 2

Episodic Treatment Options

First-Line Oral Antivirals (in order of preference)

• Valacyclovir 2g twice daily for 1 day reduces median episode duration by 1.0 day compared to placebo and offers the most convenient single-day dosing regimen 1, 2

• Famciclovir 1500mg as a single dose is equally effective, significantly reducing healing time of primary lesions with the advantage of truly single-dose administration 3, 1, 2

• Acyclovir 400mg five times daily for 5 days is effective but requires more frequent dosing and longer treatment duration, making it less convenient despite lower cost 1, 4

Topical Antiviral Options (Second-Line)

• Penciclovir 1% cream applied every 2 hours while awake for 4 days shortens lesion duration by approximately 0.5 days and is FDA-approved for adults and children ≥12 years 5

• Acyclovir 5% cream/ointment applied five times daily for 5 days provides modest benefit, primarily increasing the number of aborted lesions when applied during prodrome 6, 7

• Topical antivirals are significantly less effective than oral therapy and should only be used when oral therapy is contraindicated or refused by the patient 1, 2

Critical Timing Considerations

• Treatment must be initiated during the prodromal phase or within 24 hours of symptom onset for maximum efficacy; effectiveness decreases dramatically after lesions fully develop 1, 2

• Patient-initiated therapy at first tingling, burning, or itching sensation may prevent lesion development entirely in some cases 1

• Educate patients to keep medication readily available and start treatment immediately without waiting for physician consultation 3

Suppressive Therapy for Frequent Recurrences

Indications for Daily Suppressive Therapy

• Patients with ≥6 recurrences per year should be offered suppressive therapy 1

• Patients with severe outbreaks causing significant psychological distress or functional impairment 1

Suppressive Therapy Regimens

• 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

Efficacy and Duration

• Daily suppressive therapy reduces recurrence frequency by ≥75% among patients with frequent outbreaks 1

• Acyclovir has documented safety for up to 6 years of continuous use 1

• Valacyclovir and famciclovir have documented safety for 1 year of continuous use 1

• After 1 year of suppressive therapy, consider a trial off medication to reassess recurrence frequency, as outbreak frequency naturally decreases over time in many patients 1

Special Populations

Immunocompromised Patients

• Higher doses or longer treatment durations may be required in immunocompromised patients 1, 2

• Risk of acyclovir resistance increases to approximately 7% in immunocompromised patients compared to <0.5% in immunocompetent hosts 1

Renal Impairment

• Dose adjustment is required for all oral antivirals in patients with significant renal impairment 2

Common Pitfalls to Avoid

• Do not rely solely on topical treatments when oral therapy is indicated; topical agents provide only modest benefit compared to oral antivirals 1, 2

• Do not use traditional longer-course, lower-dose regimens when short-course, high-dose therapy (valacyclovir or famciclovir) is more effective and improves adherence 1, 2

• Do not delay treatment initiation; efficacy is time-dependent and maximal when started during prodrome 1, 2

• Do not prescribe topical antivirals for prophylaxis or suppression; they cannot reach the site of viral reactivation in the dorsal root ganglia and are ineffective for prevention 1, 2

• Do not fail to consider suppressive therapy in patients with ≥6 recurrences per year who could benefit significantly from daily prophylaxis 1

Safety Profile

• All oral antivirals (acyclovir, valacyclovir, famciclovir) are generally well-tolerated with minimal adverse events 1

• Common side effects include headache (<10%), nausea (<4%), and diarrhea, which are typically mild to moderate in intensity 1

• Development of antiviral resistance with episodic use in immunocompetent patients remains extremely low (<0.5%) 1, 2

Adjunctive Measures

• Counsel patients on trigger avoidance including UV light exposure (use lip balm with SPF), stress reduction, and fever management 1

• Discuss that suppressive therapy reduces but does not eliminate asymptomatic viral shedding 1