What is the recommended dosage of acyclovir (antiviral medication) cream for treating herpes simplex?

Acyclovir Cream Dosage for Herpes Simplex

Acyclovir cream (5%) should be applied 5 times daily for 5 days, but oral acyclovir is strongly preferred over topical formulations because topical therapy is substantially less effective and its use is discouraged. 1

Why Topical Acyclovir Is Not Recommended

• The CDC explicitly states that topical acyclovir therapy is substantially less effective than oral formulations and its use is discouraged for treating herpes simplex infections. 1
• Topical acyclovir provides no improvement in systemic symptoms and is significantly less effective than oral therapy. 2
• Oral antiviral medications are significantly more effective than topical formulations for treating cold sores and genital herpes. 3

Recommended Oral Alternatives (Preferred Over Cream)

For Recurrent Herpes Labialis (Cold Sores):

• Acyclovir 800 mg orally twice daily for 5 days (most convenient, equivalent efficacy) 3
• Acyclovir 400 mg orally 3 times daily for 5 days 3, 4
• Acyclovir 200 mg orally 5 times daily for 5 days 3

For First Episode Genital Herpes:

• Acyclovir 200 mg orally 5 times daily for 7-10 days until clinical resolution 1, 2

For Recurrent Genital Herpes:

• Acyclovir 800 mg orally twice daily for 5 days 1
• Acyclovir 400 mg orally 3 times daily for 5 days 1
• Acyclovir 200 mg orally 5 times daily for 5 days 1

Critical Timing Considerations

• Treatment must be initiated during prodrome or within 2 days of lesion onset for maximum benefit. 3, 2
• Starting therapy after this window significantly reduces effectiveness, and most immunocompetent patients with recurrent disease experience limited benefit from delayed therapy. 3
• Early treatment can reduce pain duration by 36% and healing time by 27% when started in the prodrome or erythema stage. 5

If Topical Acyclovir Cream Must Be Used

When oral therapy is not feasible and topical acyclovir 5% cream is the only option:

• Apply 5 times daily for 5 days, starting at earliest sign of recurrence 6, 7
• The combination product containing 5% acyclovir plus 1% hydrocortisone cream shows superior efficacy to acyclovir cream alone, reducing both ulcerative and nonulcerative recurrences. 6, 7
• Topical acyclovir may speed healing in immunocompromised patients with chronic ulcerative herpetic lesions when systemic therapy is not desired. 8

Special Populations Requiring Oral or IV Therapy

Immunocompromised Patients:

• Require more aggressive therapy with acyclovir 400 mg orally 3-5 times daily or IV administration. 1, 9
• May have prolonged episodes with extensive disease requiring IV acyclovir 5-10 mg/kg every 8 hours. 1

Severe Disease:

• IV acyclovir 5-10 mg/kg every 8 hours for 5-7 days for hospitalized patients with disseminated infection, pneumonitis, hepatitis, or CNS complications. 1

Important Caveats

• Acyclovir neither eradicates latent virus nor affects subsequent risk, frequency, or severity of recurrences after discontinuation. 1, 3
• Patients should abstain from activities that might spread the virus while lesions are present, though transmission can occur during asymptomatic periods. 3, 2
• Most immunocompetent patients with recurrent disease experience limited benefit from therapy overall. 1, 3