What is the recommended 3-day dosing regimen for treating a herpes breakout with oral and topical medications?

Three-Day Dosing Regimens for Herpes Breakout Treatment

For recurrent genital herpes outbreaks, prescribe valacyclovir 500 mg orally twice daily for 3 days, starting at the first sign of symptoms. 1, 2, 3

Oral Medication Prescription Example

Valacyclovir (Preferred 3-Day Regimen)

Prescription:

• Medication: Valacyclovir 500 mg tablets
• Directions: Take 1 tablet by mouth twice daily (morning and evening, approximately 12 hours apart) for 3 days
• Quantity: 6 tablets
• Refills: 2-3 (for future outbreaks)
• Instructions: Start at the first sign of tingling, itching, burning, or lesion appearance 1, 2

The FDA-approved 3-day valacyclovir regimen is the only antiviral drug approved for such a short episodic treatment course and has been shown to be equivalent to 5-day therapy for recurrent episodes. 4, 3 Clinical trials demonstrated no significant differences between 3-day versus 5-day treatment for lesion healing time (4.4 vs 4.7 days), pain duration (2.9 vs 2.5 days), or episode length (4.3 vs 4.4 days). 3

Alternative Oral Options (5-Day Regimens)

If valacyclovir is unavailable or cost-prohibitive, the CDC recommends these alternatives for recurrent episodes: 5, 1

• Acyclovir 400 mg: Take 1 tablet by mouth three times daily for 5 days (Quantity: 15 tablets) 5, 1
• Acyclovir 800 mg: Take 1 tablet by mouth twice daily for 5 days (Quantity: 10 tablets) 5
• Famciclovir 125 mg: Take 1 tablet by mouth twice daily for 5 days (Quantity: 10 tablets) 5, 1

Topical Medication: Not Recommended

There is no effective 3-day topical regimen for genital herpes, and topical acyclovir cream should not be prescribed for this indication. 1

The CDC explicitly recommends against topical acyclovir due to substantially lower effectiveness compared to oral therapy. 1 Topical antiviral therapy for genital herpes is discouraged in all major guidelines. 5

Important Note on Herpes Labialis (Cold Sores)

If the question pertains to oral herpes (cold sores) rather than genital herpes, the regimen differs:

• Valacyclovir 2 grams orally twice daily for 1 day (taken 12 hours apart) is the FDA-approved regimen for herpes labialis 2
• This is a single-day, two-dose treatment (total of 4 grams) 5, 2

Critical Prescribing Considerations

Timing of Initiation

• Episodic therapy is most effective when started during prodrome or within 1 day of lesion onset 1
• Counsel patients to keep medication on hand and begin immediately when symptoms start 1

Common Pitfall to Avoid

Do not prescribe topical acyclovir cream for genital herpes outbreaks—it provides minimal benefit and may give false reassurance. 1 Systemic oral therapy is required for meaningful clinical effect. 5

Patient Counseling Points

• Abstain from sexual activity when lesions or prodromal symptoms are present 1
• Antiviral therapy controls symptoms but does not cure the infection or prevent all future recurrences 1
• If symptoms persist beyond 5 days of treatment, consider extended therapy or evaluation for complications 1

When to Consider Suppressive Therapy Instead

For patients with ≥6 recurrences per year, daily suppressive therapy (valacyclovir 500 mg to 1 g once daily) is more appropriate than episodic treatment. 1 This reduces recurrence frequency by ≥75% and decreases asymptomatic viral shedding. 1