What are the treatment options for a herpes outbreak?

Treatment of Herpes Outbreaks

For genital herpes outbreaks, start oral antiviral therapy immediately at the first sign of symptoms, with valacyclovir 500 mg twice daily for 5 days as the preferred episodic treatment, or consider suppressive therapy with valacyclovir 1 gram daily if experiencing 6 or more recurrences per year. 1, 2

First Clinical Episode of Genital Herpes

For patients presenting with their first episode of genital herpes, the Centers for Disease Control and Prevention recommends:

• Acyclovir 400 mg orally three times daily for 7-10 days 3
• Alternative options include acyclovir 200 mg orally five times daily for 7-10 days, famciclovir 250 mg orally three times daily for 7-10 days, or valacyclovir 1 gram orally twice daily for 7-10 days 3
• Treatment may be extended beyond 10 days if healing is incomplete 3
• For severe herpes proctitis, use acyclovir 400 mg orally 5 times daily for 10 days or until clinical resolution 1

Recurrent Genital Herpes Episodes

Episodic Treatment Strategy

Episodic therapy is most effective when initiated during the prodrome or within 1 day after onset of lesions 2, 3. Patients should be provided with medication or a prescription to self-initiate treatment at the earliest symptoms 3.

Recommended episodic regimens:

• Valacyclovir 500 mg orally twice daily for 5 days (preferred option) 1, 2, 3
• Acyclovir 400 mg orally three times daily for 5 days 1, 2, 3
• Acyclovir 800 mg orally twice daily for 5 days 1, 2, 3
• Famciclovir 125 mg orally twice daily for 5 days 1, 2, 3

Clinical trial data demonstrates that valacyclovir 500 mg twice daily reduces median time to lesion healing from 6 days (placebo) to 4 days, and reduces time to cessation of viral shedding from 4 days to 2 days 4. A 3-day course of valacyclovir 500 mg twice daily showed similar efficacy to the 5-day regimen, with median healing time of approximately 4.5 days for both 4.

Suppressive Therapy

Daily suppressive therapy is recommended for patients with frequent recurrences (≥6 episodes per year) 1, 2, 3. This approach reduces recurrence frequency by ≥75% and decreases asymptomatic viral shedding 2, 3.

Recommended suppressive regimens:

• Valacyclovir 1 gram orally once daily (preferred for convenience) 1, 2, 3
• Valacyclovir 500 mg orally once daily 1, 2, 3
• Acyclovir 400 mg orally twice daily 1, 2, 3
• Famciclovir 250 mg orally twice daily 1, 2, 3

Safety and efficacy have been documented for acyclovir for up to 6 years and for valacyclovir and famciclovir for 1 year 3. After 1 year of continuous suppressive therapy, consider discontinuation to reassess recurrence frequency 2, 3.

Herpes Labialis (Cold Sores)

For oral herpes outbreaks, ultra-short course therapy is highly effective:

• Famciclovir 1500 mg as a single dose 5, 6
• Valacyclovir 2 grams twice daily for 1 day 4

Single-dose famciclovir significantly reduced time to healing of primary vesicular lesions and time to return to normal skin compared to placebo 5. The 1-day valacyclovir regimen shortened mean duration of cold sore episodes by approximately 1 day compared to placebo 4.

Severe Disease Requiring Hospitalization

For severe genital herpes or complications requiring hospitalization:

• Acyclovir 5-10 mg/kg IV every 8 hours for 5-7 days or until clinical resolution 1, 3

Critical Clinical Considerations

What NOT to Use

Topical acyclovir is substantially less effective than oral therapy and is NOT recommended 1, 2, 3. This is a common pitfall—patients may request topical therapy thinking it's safer, but it provides minimal benefit.

Antiviral Resistance

• Antiviral resistance is rare in immunocompetent patients but more common in immunocompromised individuals 1, 3
• Suspect acyclovir resistance if lesions do not begin to resolve within 7-10 days of therapy 2
• For proven or suspected resistance, use foscarnet 40 mg/kg IV every 8 hours 2

Patient Counseling Essentials

Patients must understand that:

• Antiviral medications control symptoms but do not eradicate the virus or prevent all recurrences 2, 3
• Asymptomatic viral shedding can occur, potentially leading to transmission 1, 2
• Abstain from sexual activity when lesions or prodromal symptoms are present 1, 2, 3
• Use condoms during all sexual exposures with new or uninfected partners 1, 2, 3
• Inform sex partners about having genital herpes 2, 3

Special Populations

HIV-infected patients: For recurrent orolabial or genital herpes, use famciclovir 500 mg orally twice daily for 7 days 6. In one trial of HIV-infected adults on stable antiretroviral therapy, valacyclovir 500 mg twice daily for 6 months resulted in 65% of patients remaining recurrence-free versus 26% on placebo 4.

Pregnancy: The safety of systemic acyclovir and valacyclovir in pregnancy has not been definitively established, though routine suppressive therapy is not recommended during pregnancy for recurrent genital herpes 2. Pregnant women with genital herpes should inform their healthcare providers about the HSV infection due to risk of neonatal transmission 3.

Prognostic Information

HSV-1 causes 5-30% of first-episode genital herpes cases, with clinical recurrences being much less frequent than with HSV-2 3. Identification of the infecting strain (HSV-1 vs HSV-2) has prognostic importance and is useful for counseling 3. Asymptomatic viral shedding occurs more frequently in patients with HSV-2 infection and in those who have had genital herpes for less than 12 months 3.