What is the recommended treatment for oral herpes?

Recommended Treatment for Oral Herpes

For episodic treatment of oral herpes (cold sores), initiate valacyclovir 2g twice daily for 1 day at the first sign of symptoms, which is the most effective and convenient first-line therapy. 1, 2

Treatment Algorithm for Episodic Outbreaks

First-Line Therapy

• Valacyclovir 2g twice daily for 1 day is the preferred initial treatment due to its high bioavailability, convenient single-day dosing, and proven efficacy in reducing episode duration by approximately 1 day compared to placebo 1, 2
• Treatment must be initiated within 24 hours of symptom onset—ideally during the prodromal phase (tingling, burning sensation)—as peak viral titers occur in the first 24 hours and efficacy decreases significantly after lesions fully develop 1

Alternative Oral Regimens

• Famciclovir 1500mg as a single dose is equally effective and offers the most convenient dosing schedule, significantly reducing healing time of primary lesions 1, 3
• Acyclovir 400mg five times daily for 5 days is another option but requires more frequent dosing and is less convenient, though it remains effective 1, 2

Why Oral Therapy Over Topical

• Oral antivirals are substantially more effective than topical treatments, which provide only modest clinical benefit 1
• Topical antivirals cannot reach the site of viral reactivation in nerve ganglia and are therefore ineffective for suppression 1

Suppressive Therapy for Frequent Recurrences

Indications

• Patients with ≥6 recurrences per year should be offered daily suppressive therapy 1
• Consider suppression for patients with severe episodes, significant psychological distress, or complicated disease 1

Suppressive 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

Expected Outcomes and Duration

• Daily suppressive therapy reduces recurrence frequency by ≥75% 1
• Safety is documented for acyclovir up to 6 years and for valacyclovir/famciclovir for 1 year of continuous use 1
• After 1 year of suppression, discontinue therapy temporarily to reassess recurrence rate, as frequency naturally decreases over time in many patients 1

Special Populations and Resistance

Immunocompromised Patients

• Episodes are typically longer, more severe, and may involve the oral cavity or extend across the face 1
• Higher doses or longer treatment durations may be required 1
• Acyclovir resistance rates are significantly higher (7% vs <0.5% in immunocompetent patients) 1, 4

Management of Treatment Failure

• For confirmed acyclovir-resistant HSV, IV foscarnet 40mg/kg three times daily is the treatment of choice 1, 4
• Resistance to oral antivirals when used episodically in immunocompetent patients remains extremely low (<0.5%) 1

Critical Pitfalls to Avoid

• Do not rely on topical treatments alone—they are significantly less effective than oral therapy and cannot prevent recurrences 1
• Do not start treatment too late—efficacy plummets when initiated after lesions have fully developed; patient-initiated therapy at first symptoms may even prevent lesion development 1
• Do not fail to consider suppressive therapy in patients with ≥6 recurrences per year who could benefit substantially 1
• Do not use inadequate dosing—short-course, high-dose therapy (valacyclovir 2g BID x1 day or famciclovir 1500mg x1) is more effective than traditional longer courses with lower doses 1

Safety Profile

• All oral antivirals are generally well-tolerated with minimal adverse events 1, 5
• Common side effects include headache (<10%), nausea (<4%), and diarrhea, which are typically mild to moderate in intensity 1, 5
• The combination of oral valacyclovir plus topical clobetasol gel 0.05% has shown efficacy with mild and infrequent adverse events for severe cases 1

Preventive Counseling

• Counsel patients to identify and avoid personal triggers including UV light exposure, fever, psychological stress, and menstruation 1
• Emphasize that suppressive therapy reduces but does not eliminate asymptomatic viral shedding 1
• Discuss trigger avoidance even while on suppressive therapy 1