What is the treatment for recurrent Herpes Simplex Virus (HSV) infection?

Treatment for Recurrent HSV Infection

For recurrent HSV infections, initiate episodic antiviral therapy with valacyclovir 500 mg orally twice daily for 5 days at the first sign of prodrome or lesion onset, or consider daily suppressive therapy with valacyclovir 500-1000 mg once daily if experiencing ≥6 recurrences per year. 1

Episodic Treatment for Recurrent Episodes

Start treatment immediately at the first sign of prodrome (tingling, burning, itching) or within 1 day of lesion appearance for maximum effectiveness. 1, 2

First-Line Episodic Regimens (Choose One):

• Valacyclovir 500 mg orally twice daily for 5 days 3, 1
• Acyclovir 400 mg orally three times daily for 5 days 3, 1
• Acyclovir 800 mg orally twice daily for 5 days 3, 1
• Famciclovir 125 mg orally twice daily for 5 days 3, 1

Alternative Short-Course Regimens:

• Valacyclovir 2 grams twice daily for 1 day (genital herpes) 4
• Famciclovir 1000 mg twice daily for 1 day (genital herpes) 5
• Famciclovir 1500 mg as a single dose (herpes labialis/cold sores) 6, 5

Valacyclovir and famciclovir offer more convenient dosing compared to acyclovir's five-times-daily regimen, which may improve adherence. 3, 7

Suppressive Therapy for Frequent Recurrences

Daily suppressive therapy is indicated for patients with ≥6 recurrences per year and reduces recurrence frequency by ≥75%. 3, 1

Recommended Suppressive Regimens (Choose One):

• Valacyclovir 500-1000 mg orally once daily 3, 1
• Acyclovir 400 mg orally twice daily 3, 1
• Famciclovir 250 mg orally twice daily 3, 1

Note: Valacyclovir 500 mg once daily may be less effective in patients with ≥10 episodes per year; use higher doses in this population. 3

Duration and Reassessment:

• Safety documented for acyclovir up to 6 years and valacyclovir/famciclovir for 1 year. 3, 1
• After 1 year of suppressive therapy, discuss discontinuation to reassess recurrence frequency, as episodes often decrease over time. 3, 1
• Suppressive therapy reduces but does not eliminate asymptomatic viral shedding. 3, 1

Site-Specific Considerations

Genital Herpes:

• Episodic treatment most effective when initiated during prodrome or within 24 hours of symptom onset. 1, 4
• Median time to lesion healing: 4 days with valacyclovir 500 mg twice daily versus 6 days with placebo. 4

Oral Herpes (Herpes Labialis):

• Valacyclovir 500 mg twice daily for 5 days or famciclovir 1500 mg single dose are effective first-line options. 2, 6
• Treatment beyond 72 hours after symptom onset significantly reduces effectiveness. 2

Severe Disease Requiring Hospitalization

For severe HSV disease with complications (disseminated infection, pneumonitis, hepatitis, meningitis, encephalitis), use acyclovir 5-10 mg/kg IV every 8 hours for 5-7 days or until clinical resolution. 3, 8

Special Populations

HIV-Infected Patients:

• For recurrent orolabial or genital herpes: famciclovir 500 mg orally twice daily for 7 days. 8, 6
• Suppressive therapy: valacyclovir 500 mg twice daily reduces recurrences by 65% versus 26% with placebo. 4
• Acyclovir resistance is more common in immunocompromised patients than immunocompetent individuals. 2, 8, 9

Renal Impairment:

• Adjust all antiviral doses based on creatinine clearance to prevent acute renal failure. 6

Critical Pitfalls to Avoid

• Never use topical acyclovir—it is substantially less effective than oral therapy. 1, 8
• Do not delay treatment beyond 72 hours of symptom onset, as efficacy drops significantly. 2
• Do not fail to consider suppressive therapy in patients with frequent recurrences (≥6 per year). 1, 2
• Do not use valacyclovir 500 mg once daily in patients with ≥10 episodes per year—use higher doses. 3

Patient Counseling Points

• Antiviral medications control symptoms but do not eradicate the virus or prevent all recurrences. 1, 2
• Abstain from sexual activity when lesions or prodromal symptoms are present. 1, 8
• Use condoms during all sexual exposures with new or uninfected partners. 1, 8
• Asymptomatic viral shedding can occur and may lead to transmission even without visible lesions. 1, 8
• Provide patients with medication or prescription to self-initiate treatment at first sign of recurrence. 3, 1