What are the management options for recurrent Herpes Simplex Virus (HSV) infection?

From the Guidelines

For patients with recurrent herpes simplex virus (HSV) infections, daily suppressive therapy with antiviral medications such as acyclovir 400mg twice daily, valacyclovir 500mg daily, or famciclovir 250mg twice daily is recommended to reduce the frequency of recurrences by 70-80%. This approach is particularly beneficial for patients experiencing frequent recurrences, defined as more than 6 episodes per year 1. The goal of suppressive therapy is to decrease the frequency and severity of outbreaks, as well as reduce the risk of transmission.

Key Considerations

• Patient education is crucial, including trigger avoidance (stress, illness, sunlight exposure), maintaining good hygiene during outbreaks, and abstaining from sexual contact when lesions are present.
• Antiviral medications work by inhibiting viral DNA polymerase, preventing HSV replication, although they cannot eliminate the latent virus in sensory ganglia.
• After 12 months of suppressive therapy, consider discontinuation to reassess recurrence frequency, as some patients may experience fewer outbreaks over time 1.

Treatment Options

• Episodic treatment: acyclovir 400mg three times daily for 5 days, valacyclovir 1g twice daily for 3 days, or famciclovir 125mg twice daily for 5 days.
• Suppressive therapy: acyclovir 400mg twice daily, valacyclovir 500mg daily (or 1g daily for patients with more than 10 episodes yearly), or famciclovir 250mg twice daily.

Special Considerations

• Immunocompromised patients, such as those with inflammatory bowel disease, may be at increased risk for severe and extensive HSV infections 1.
• Routine prophylaxis to suppress virus replication should be considered for patients with frequent recurrent attacks, who are already taking intermittent suppressive antiviral therapy, or both.

From the FDA Drug Label

Immunocompetent Adult Patients( 1. 1) • Herpes labialis (cold sores) o Treatment of recurrent episodes • Genital herpes o Treatment of recurrent episodes o Suppressive therapy of recurrent episodes • Herpes zoster (shingles) Human Immunodeficiency Virus (HIV)-Infected Adult Patients( 1. 2) • Treatment of recurrent episodes of orolabial or genital herpes

The management of recurrent HSV includes treatment of recurrent episodes and suppressive therapy of recurrent episodes for genital herpes, as well as treatment of recurrent episodes for herpes labialis (cold sores) and orolabial or genital herpes in HIV-infected patients.

• Famciclovir 2 and Famciclovir 2 are indicated for the treatment of recurrent episodes of herpes labialis, genital herpes, and herpes zoster in immunocompetent adult patients.
• Valacyclovir 3 is used for the treatment of genital herpes, with patients advised to initiate therapy at the first sign or symptom of an episode. Key points:
• Initiate treatment as soon as possible after a diagnosis of herpes zoster or at the earliest sign or symptom of a cold sore or genital herpes episode.
• Patients should be advised to use safer sex practices in combination with suppressive therapy to reduce the risk of transmitting the infection to partners.

From the Research

Management of Recurrent HSV

• Antiviral management options for recurrent herpes simplex virus (HSV) infection include daily suppressive and episodic therapy 4.
• Patient-initiated, short-course, high-dose antiviral therapy is a new and more convenient option for patients who choose episodic therapy 4.
• Suppressive valaciclovir and famciclovir treatment have comparable clinical benefits, but valaciclovir may have a greater impact on virological end-points 4.
• Famciclovir effectively reduces the frequency of total and subclinical HSV shedding compared with placebo, as well as the percentage of days with genital lesions for subjects with or without a history of genital herpes 4.

Treatment Options

• Oral aciclovir 200mg 5 times daily for 5 days is the recommended treatment for initial genital HSV infection 5.
• Topical aciclovir may be of benefit, but it does not improve systemic symptoms 5.
• Episodic treatment with oral aciclovir initiated early by the patient appears to have the most favorable results, and may abort the episode in some patients if initiated at the onset of prodromal symptoms 5.
• Suppressive therapy with oral aciclovir should be considered in patients with frequent recurrences, with a starting dose of 200mg 4 times daily 5.

Comparative Efficacy of Antivirals

• Daily antiviral therapy with famciclovir and valacyclovir has been shown to be effective in reducing both symptomatic and asymptomatic reactivation of HSV-2 6.
• Valacyclovir appears to be somewhat better than famciclovir for suppression of genital herpes and associated shedding 6.
• Acyclovir, valacyclovir, and famciclovir are efficacious and safe for the treatment of the first episode and recurrent genital herpes, and are useful as suppressive therapy for individuals with frequent genital herpes recurrences 7.