What is the recommended treatment for herpes breakout, including pain relief and antiviral medication?

Treatment for Herpes Breakout

For a herpes breakout, initiate oral antiviral therapy immediately—valacyclovir 500 mg twice daily for 3-5 days is the preferred first-line treatment for recurrent episodes, and naproxen (Aleve) 220-440 mg every 8-12 hours can be used for pain relief. 1, 2

Antiviral Medication Regimen

Episodic therapy should be started at the first sign of prodrome or within 24 hours of lesion onset for maximum effectiveness. 1, 2

First-Line Options for Recurrent Episodes:

• Valacyclovir 500 mg orally twice daily for 3 days (FDA-approved short course) 2
• Valacyclovir 500 mg orally twice daily for 5 days 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

The CDC emphasizes that topical acyclovir is substantially less effective than oral therapy and should not be used, despite being available over-the-counter. 1, 3 This is a critical pitfall to avoid—patients often reach for topical formulations thinking they're equivalent, but clinical trials demonstrate oral therapy reduces outbreak duration by approximately 1 day compared to topical agents. 4, 5

Pain Management

Naproxen (Aleve) is appropriate for pain relief during herpes outbreaks. Standard dosing is 220-440 mg every 8-12 hours as needed, not exceeding 660 mg in 24 hours for OTC use. NSAIDs like naproxen address the inflammatory component of herpetic pain effectively.

Additional Pain Management Considerations:

• Pain typically resolves within 3-4 days with antiviral therapy 2
• For severe pain, consider adding acetaminophen or consulting for prescription analgesics
• Topical lidocaine may provide additional symptomatic relief (though not addressing viral replication)

When to Consider Suppressive Therapy

If experiencing 6 or more recurrences per year, daily suppressive therapy should be initiated rather than episodic treatment. 1, 3

Suppressive Therapy Options:

• Valacyclovir 1 gram orally once daily 1
• Valacyclovir 500 mg orally once daily (for ≤9 recurrences/year) 1, 2
• Acyclovir 400 mg orally twice daily 1
• Famciclovir 250 mg orally twice daily 1

Suppressive therapy reduces recurrence frequency by ≥75% and has documented safety for up to 6 years with acyclovir. 1, 3 After 1 year of continuous suppressive therapy, the CDC recommends discontinuation to reassess recurrence frequency. 1

Critical Clinical Pearls

Patients should keep antiviral medication on hand to self-initiate treatment immediately when prodromal symptoms begin (tingling, itching, burning), as efficacy decreases significantly if treatment is delayed beyond 24 hours of symptom onset. 1, 2

Important Counseling Points:

• Abstain from sexual activity when lesions or prodromal symptoms are present 1, 3
• Asymptomatic viral shedding can occur, potentially leading to transmission even without visible lesions 1, 3
• Condoms should be used during all sexual exposures with new or uninfected partners 1, 3
• Antivirals control symptoms but do not eradicate the virus or prevent all future recurrences 1

When to Escalate Care

If lesions do not begin to resolve within 7-10 days of oral antiviral therapy, suspect acyclovir resistance (rare in immunocompetent patients but possible). 1, 6 In such cases, foscarnet 40 mg/kg IV every 8 hours is the alternative treatment. 1, 6

For severe disease requiring hospitalization (disseminated infection, encephalitis), intravenous acyclovir 5-10 mg/kg every 8 hours is indicated. 3