What is the treatment for herpes?

Treatment of Herpes Infections

Oral antiviral medications—valacyclovir, famciclovir, or acyclovir—are the most effective treatment for herpes infections, with the specific regimen depending on whether you are treating herpes labialis (cold sores), genital herpes, or determining if suppressive therapy is needed. 1

Treatment by Herpes Type

Herpes Labialis (Cold Sores)

First-line treatment is valacyclovir 2 grams twice daily for 1 day, initiated at the earliest symptoms or prodrome. 1, 2 This single-day, high-dose regimen reduces median episode duration by approximately 1 day compared to placebo and offers superior convenience over traditional longer courses. 1

Alternative regimens include:

• Famciclovir 1500 mg as a single dose 1, 3
• Acyclovir 400 mg five times daily for 5 days (requires more frequent dosing) 1

Critical timing: Treatment must begin within 24 hours of symptom onset or during the prodromal phase for maximum efficacy, as peak viral titers occur in the first 24 hours after lesion onset. 1, 4 Starting treatment after lesions have fully developed significantly reduces efficacy. 1

Genital Herpes

First Episode

For initial genital herpes, use acyclovir 400 mg orally three times daily for 7-10 days, OR valacyclovir 1 gram twice daily for 10 days. 1, 2 Both regimens are equally effective, with median time to lesion healing of 9 days, cessation of pain at 5 days, and cessation of viral shedding at 3 days. 2, 5

Recurrent Episodes

For episodic treatment of recurrent genital herpes, use one of the following regimens: 6

• Acyclovir 400 mg orally three times daily for 5 days 6
• Acyclovir 800 mg orally twice daily for 5 days 6
• Famciclovir 125 mg orally twice daily for 5 days 6
• Valacyclovir 500 mg orally twice daily for 5 days 6
• Alternatively, valacyclovir 1000 mg twice daily for 1 day (shorter course option) 1, 2

Treatment should be initiated during the prodrome or within 1 day after onset of lesions for maximum benefit. 6 The median time to lesion healing with valacyclovir 500 mg twice daily is 4 days versus 6 days with placebo. 2

Suppressive Therapy

Daily suppressive therapy is indicated for patients with six or more recurrences per year and reduces recurrence frequency by ≥75%. 6, 1

Recommended suppressive regimens: 6, 1

• Acyclovir 400 mg orally twice daily
• Famciclovir 250 mg orally twice daily
• Valacyclovir 500 mg once daily (can increase to 1000 mg once daily for very frequent recurrences) 1

Duration considerations: Safety and efficacy have been documented for acyclovir for up to 6 years and for valacyclovir/famciclovir for 1 year. 6, 1 After 1 year of continuous suppressive therapy, consider discontinuation to reassess recurrence frequency, as it decreases over time in many patients. 6, 1

Oral Herpes (Herpetic Gingivostomatitis)

For mild oral herpetic lesions, initiate valacyclovir 1 gram twice daily for 5-10 days, OR famciclovir 500 mg twice daily, OR acyclovir 400 mg three times daily for the same duration. 4

For moderate to severe herpetic gingivostomatitis, initiate IV acyclovir 5-10 mg/kg body weight every 8 hours, then transition to oral therapy once lesions begin to regress. 4

Special Populations

HIV-Infected Patients

For recurrent orolabial or genital herpes in HIV-infected patients, use famciclovir 500 mg twice daily for 7 days. 3 Standard oral doses should be used but with extended duration to 7-14 days. 4 Short-course (1-3 day) therapy should not be used in HIV-infected patients. 4

Immunocompromised Patients

Episodes are typically longer and more severe in immunocompromised patients, potentially involving the oral cavity or extending across the face. 1 Higher doses or longer treatment durations may be required. 1

For acyclovir-resistant HSV (more common in immunocompromised patients with resistance rates up to 7% versus <0.5% in immunocompetent hosts), IV foscarnet 40 mg/kg three times daily is the treatment of choice. 1

Important Clinical Considerations

Topical antivirals are substantially less effective than oral therapy and should not be used as primary treatment. 1, 4 They provide only modest clinical benefit and cannot reach sites of viral reactivation. 1

Suppressive therapy reduces but does not eliminate asymptomatic viral shedding, so the extent to which it prevents HSV transmission is uncertain. 6, 1

Resistance to oral antiviral agents when used episodically in immunocompetent patients is unlikely, with rates remaining below 0.5%. 6, 1

Common Pitfalls to Avoid

• Delaying treatment initiation: Waiting until lesions fully develop significantly reduces efficacy. 1, 4
• Relying on topical treatments: These are substantially less effective than oral agents. 1, 4
• Inadequate dosing: Not using appropriate short-course, high-dose therapy when indicated. 1
• Failing to consider suppressive therapy: Patients with ≥6 recurrences per year could significantly benefit. 1
• Not discussing triggers: Patients should identify and avoid personal triggers including UV light exposure, stress, fever, and menstruation. 1

Counseling Points

Patients should be advised about: 6

• The natural history of the disease with potential for recurrent episodes
• Asymptomatic viral shedding and sexual transmission risk
• Abstaining from sexual activity when lesions or prodromal symptoms are present
• Using condoms during all sexual exposures with new or uninfected partners
• The risk for neonatal infection (relevant for childbearing-aged women)