What is the recommended treatment for herpes?

Treatment Selection for Herpes Infections

The choice of treatment for herpes depends primarily on the type of herpes infection (genital HSV, orolabial HSV, or herpes zoster), whether it is a first episode versus recurrent disease, and the patient's immune status. Here is an algorithmic approach to selecting the appropriate antiviral regimen:

Step 1: Identify the Type and Timing of Herpes Infection

Genital Herpes - First Clinical Episode

• For initial genital herpes, prescribe valacyclovir 1 gram orally twice daily for 10 days, which is as effective as acyclovir and offers more convenient dosing 1.
• Alternative: Acyclovir 200 mg orally 5 times daily for 7-10 days until clinical resolution 2.
• Treatment is most effective when started within 48 hours of symptom onset 1.

Genital Herpes - Recurrent Episodes

• For recurrent genital herpes, use valacyclovir 500 mg orally twice daily for 3 days, which is the shortest FDA-approved episodic treatment regimen 3, 1.
• Alternative options include acyclovir 400 mg orally 3 times daily for 5 days, acyclovir 800 mg orally twice daily for 5 days, or famciclovir 125 mg orally twice daily for 5 days 3.
• Episodic therapy must be initiated during prodrome or within 1 day of lesion onset to be effective 3.
• Important caveat: Most immunocompetent patients with recurrent disease derive limited benefit from episodic treatment since early administration is rarely feasible 2.

Genital Herpes - Suppressive Therapy

• For patients with ≥6 recurrences per year, prescribe daily suppressive therapy with valacyclovir 1 gram orally once daily, which reduces recurrence frequency by ≥75% 3, 1.
• For patients with 9 or fewer recurrences per year, valacyclovir 500 mg orally once daily is an acceptable alternative 3, 1.
• Alternative suppressive regimens: acyclovir 400 mg orally twice daily or famciclovir 250 mg orally twice daily 3.
• After 1 year of continuous suppressive therapy, discontinue treatment to reassess the patient's recurrence rate 2, 3.

Orolabial Herpes (Cold Sores)

• For herpes labialis, prescribe valacyclovir 2 grams orally twice daily for 1 day (two doses 12 hours apart), initiated at the earliest symptom such as tingling, itching, or burning 1.
• This is the only FDA-approved oral antiviral for cold sores and offers the most convenient single-day regimen 4.

Herpes Zoster (Shingles)

• For herpes zoster, prescribe valacyclovir 1 gram orally 3 times daily for 7 days, which is more effective than acyclovir at reducing zoster-associated pain and postherpetic neuralgia 5, 1, 6.
• Alternative: Acyclovir 800 mg orally 5 times daily for 7 days 5.
• Treatment should be initiated within 72 hours of rash onset, though some benefit may occur with later initiation 5, 6.

Step 2: Assess for Severe Disease or Complications

Severe or Disseminated Disease

• For severe herpes requiring hospitalization (disseminated infection, encephalitis, pneumonitis, hepatitis), use intravenous acyclovir 5-10 mg/kg every 8 hours for 5-7 days or until clinical resolution 2, 5.
• Switch to oral therapy once clinical improvement occurs 5.

Herpes Proctitis

• For first episode herpes proctitis, use acyclovir 400 mg orally 5 times daily for 10 days 2.

Step 3: Consider Special Populations

Immunocompromised Patients

• Immunocompromised patients require higher doses and longer treatment duration: acyclovir 400 mg orally 3-5 times daily until clinical resolution 7.
• For severe cases, use intravenous acyclovir 5-10 mg/kg every 8 hours 7, 5.
• In HIV-infected patients with CD4+ ≥100 cells/mm³, use valacyclovir 500 mg orally twice daily for suppressive therapy 1.
• Monitor closely for dissemination and complications 5.

Acyclovir-Resistant Cases

• If lesions fail to improve within 7-10 days of acyclovir therapy, suspect resistance and switch to foscarnet 40 mg/kg IV every 8 hours until clinical resolution 3, 5.
• Acyclovir-resistant strains are also resistant to ganciclovir 5.

Step 4: Avoid Common Pitfalls

What NOT to Do

• Never use topical acyclovir—it is substantially less effective than oral therapy and is strongly discouraged 2, 3.
• Avoid valacyclovir 8 grams per day in immunocompromised patients due to risk of hemolytic uremic syndrome/thrombotic thrombocytopenic purpura 3.
• Do not routinely treat recurrent episodes in immunocompetent patients unless treatment can be initiated during prodrome 2.

Key Advantages of Valacyclovir Over Acyclovir

• Valacyclovir offers superior convenience with less frequent dosing (once to three times daily versus five times daily for acyclovir), which improves adherence 4, 8, 9.
• Valacyclovir achieves higher bioavailability than acyclovir, resulting in equivalent or superior efficacy 4, 10, 8.
• For herpes zoster specifically, valacyclovir reduces duration of zoster-associated pain and postherpetic neuralgia more effectively than acyclovir 6.
• Both medications have similar safety profiles 10, 8.

Patient Counseling Points

• Advise patients to abstain from sexual activity when lesions or prodromal symptoms are present 2, 3.
• Inform patients that asymptomatic viral shedding can occur, potentially leading to transmission even without visible lesions 2, 3.
• Emphasize that antiviral therapy controls symptoms but does not eradicate latent virus or prevent all future recurrences 2, 3.
• Recommend condom use during all sexual exposures with new or uninfected partners 2, 3.