What is the treatment for orolabial herpes?

Treatment of Orolabial Herpes (Cold Sores)

For immunocompetent adults with orolabial herpes, initiate valacyclovir 2g twice daily for 1 day OR famciclovir 1500mg as a single dose at the first sign of symptoms (tingling, itching, burning, or lesion appearance). 1, 2

First-Line Episodic Treatment

Preferred Oral Antiviral Regimens

• Valacyclovir 2g twice daily for 1 day is the American Academy of Dermatology's first-line recommendation, reducing median episode duration by 1.0 day compared to placebo (p=0.001) 2
• Famciclovir 1500mg as a single dose is equally effective, significantly reducing healing time of primary lesions with FDA approval for this indication 2, 3
• Both regimens offer superior convenience compared to traditional multi-day courses, improving adherence and allowing complete medication delivery when viral replication is highest 1, 2

Alternative Regimen

• Acyclovir 400mg five times daily for 5 days is an option but requires more frequent dosing and is less convenient 1

Critical Timing Considerations

• Treatment must be initiated during the prodromal phase or within 24 hours of symptom onset for maximum efficacy, as peak viral titers occur in the first 24 hours after lesion onset 1, 2
• Patient-initiated therapy at first symptoms may prevent lesion development in some cases 1
• Efficacy decreases significantly when treatment starts after lesions have fully developed 1

Suppressive Therapy for Frequent Recurrences

Indications

• Patients with 6 or more recurrences per year should be offered suppressive therapy 1
• Consider suppressive therapy for patients with particularly severe episodes or significant psychological distress from recurrences 1

Suppressive Regimens

• Valacyclovir 500mg once daily (can increase to 1000mg once daily for very frequent recurrences) 1
• Famciclovir 250mg twice daily 1, 3
• Acyclovir 400mg twice daily 1
• Daily suppressive therapy reduces recurrence frequency by ≥75% 1

Duration and Monitoring

• Valacyclovir and famciclovir have documented safety for 1 year of continuous use 1
• Acyclovir safety is documented for up to 6 years 1
• After 1 year of suppressive therapy, consider a trial off therapy to reassess recurrence frequency, as it decreases over time in many patients 1

Special Populations

HIV-Infected Patients

• Famciclovir 500mg twice daily for 7 days is FDA-approved for recurrent orolabial herpes in HIV-infected adults 3
• Treatment must be initiated within 48 hours of symptom onset 3
• Episodes are typically longer and more severe, potentially involving the oral cavity or extending across the face 1

Immunocompromised Patients

• Higher doses or longer treatment durations may be required 1, 2
• Acyclovir resistance rates are higher (7% vs <0.5% in immunocompetent patients) 1
• For confirmed acyclovir-resistant HSV, IV foscarnet 40mg/kg three times daily is the treatment of choice 1

Renal Impairment

• Dose adjustment is required for patients with significant renal impairment to prevent acute renal failure 3
• For creatinine clearance 20-39 mL/min: famciclovir 500mg every 24 hours 3
• For creatinine clearance <20 mL/min: famciclovir 250mg every 24 hours 3

Topical Therapy: Limited Role

• Topical antivirals provide only modest clinical benefit and are significantly less effective than oral therapy 1, 2
• Topical agents are not effective for suppressive therapy as they cannot reach the site of viral reactivation 1, 2

Common Pitfalls to Avoid

• Do not rely solely on topical treatments when oral therapy is more effective 1, 2
• Do not use traditional longer courses when short-course, high-dose therapy is more effective 1, 2
• Do not delay treatment initiation beyond 24 hours of symptom onset, as efficacy decreases significantly 1, 2
• Do not fail to consider suppressive therapy in patients with ≥6 recurrences per year who could significantly benefit 1

Preventive Counseling

• Counsel patients to identify and avoid personal triggers including ultraviolet light exposure, fever, psychological stress, and menstruation 1
• Advise that suppressive therapy reduces but does not eliminate asymptomatic viral shedding 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 1
• Resistance to oral antivirals remains low (<0.5%) in immunocompetent hosts when used episodically 1, 2