Treatment of HSV-1 Without Active Outbreak
For HSV-1 infection without a current outbreak, treatment is generally not recommended unless the patient experiences frequent recurrences (≥6 episodes per year), in which case daily suppressive therapy should be initiated. 1, 2
When Treatment is NOT Indicated
- Asymptomatic HSV-1 carriers without active lesions do not require antiviral treatment. 3
- Most immunocompetent patients with infrequent recurrent disease do not benefit from continuous antiviral therapy. 3
- The absence of an outbreak means there is no indication for episodic treatment. 1, 2
When Suppressive Therapy IS Indicated
Daily suppressive therapy should be considered for patients with ≥6 recurrences per year. 1, 2 This approach:
- Reduces the frequency of HSV recurrences by at least 75%. 3, 1, 2
- Decreases asymptomatic viral shedding, which can reduce transmission risk. 1
- Has documented safety for up to 6 years with acyclovir and 1 year with valacyclovir. 1
Recommended Suppressive Regimens
First-line options for daily suppressive therapy include: 1, 2
- Valacyclovir 500 mg orally once daily (preferred for convenience of once-daily dosing) 1
- Valacyclovir 1 g orally once daily 1
- Acyclovir 400 mg orally twice daily 3, 1
- Famciclovir 250 mg orally twice daily 1
Patient Counseling and Management Strategy
All HSV-1 patients should receive counseling regardless of whether they are on suppressive therapy: 2
- Inform patients about the chronic nature of HSV-1 infection and potential for recurrence. 2
- Counsel on safe sex practices, including condom use, to reduce transmission risk. 2
- Explain that asymptomatic viral shedding can occur even without visible lesions. 3, 1
- Discuss the risk of neonatal infection with all patients, including men. 3, 2
Prescription for Future Recurrences
Provide patients with a prescription for antiviral medication to self-initiate at the first sign of recurrence (prodrome). 2 This strategy is critical because:
- Treatment is most effective when started during the prodromal period or within 24 hours of lesion onset. 1, 2
- Delaying treatment beyond 72 hours significantly reduces effectiveness. 4
Reassessment Strategy
After 1 year of continuous suppressive therapy, discontinue treatment to reassess the patient's recurrence frequency. 3, 1 This allows determination of whether ongoing suppression remains necessary.
Common Pitfalls to Avoid
- Do not use topical acyclovir alone - it is substantially less effective than systemic treatment. 1, 2, 4
- Do not initiate suppressive therapy in patients with infrequent recurrences (fewer than 6 per year), as the benefit does not justify continuous medication. 3, 1
- Do not fail to provide a prescription for episodic treatment even if the patient is not on suppressive therapy, as early self-initiated treatment is crucial. 2