Treatment of Recurrent Eye Herpes Gladiatorum
For recurrent eye herpes gladiatorum, initiate combination therapy with both oral antiviral (valacyclovir 500 mg 2-3 times daily OR acyclovir 400 mg five times daily) AND topical antiviral (ganciclovir 0.15% gel 3-5 times daily), as oral therapy alone is insufficient to prevent progression of corneal disease. 1, 2
Acute Treatment Regimen
Combination Therapy (Required)
Oral antivirals:
- Valacyclovir 500 mg twice daily for 7 days (preferred for athletes due to better compliance with twice-daily dosing) 3
- Alternative: Acyclovir 400 mg five times daily for 7-10 days 1, 2
- Alternative: Famciclovir 250 mg twice daily for 7-10 days 1
Topical antivirals (must be added):
- Ganciclovir 0.15% ophthalmic gel 3-5 times daily (preferred due to superior tolerability and less ocular surface toxicity) 2
- Alternative: Trifluridine 1% solution 5-8 times daily 1, 2
Critical Management Points
- Treatment must be initiated within 24 hours of symptom onset to achieve maximum benefit, shortening HSV PCR clearance time by 21% (from ~8.1 days to 6.4 days) 3
- Topical corticosteroids are absolutely contraindicated in active epithelial disease as they potentiate viral replication and worsen infection 2
- Athletes must be isolated from competition for 3-8 days until all lesions are fully crusted 3
- Ensure adequate hydration when using valacyclovir to minimize nephrotoxicity risk 3
Suppressive Therapy for Prevention
For athletes with history of recurrent herpes gladiatorum, long-term suppressive therapy is strongly recommended:
Preferred Regimen
- Valacyclovir 500 mg once daily (shown to be as effective as acyclovir with better compliance) 4
- Alternative: Acyclovir 400 mg twice daily 4, 5
Evidence for Suppression
- Long-term suppression reduces recurrence rate of ocular HSV disease from 32% to 19% over 12 months 5
- For patients with history of stromal keratitis specifically, suppression reduces recurrence from 28% to 14% 5
- In athletes with recurrent herpes gladiatorum, suppression reduces recurrence rate to 17.2% compared to 47.3% without prophylaxis 6
- Duration: Continue for at least 12 months, with consideration for longer duration in high-risk athletes 5
Follow-Up Protocol
- Schedule follow-up within 1 week including visual acuity measurement and slit-lamp biomicroscopy 1, 2
- Monitor for treatment response; if no improvement after 5-7 days on standard therapy, consider acyclovir-resistant HSV 7
- For apparent resistance, escalate to higher doses or alternative agents (foscarnet 40 mg/kg IV three times daily) 7
Return-to-Competition Criteria
Athletes may return to wrestling/contact sports only when:
- All lesions are fully crusted (no active vesicles or ulcers) 3
- OR physician provides written statement that condition is non-infectious 3
- Minimum isolation period of 3-8 days during active outbreak 3
Common Pitfalls to Avoid
- Never use oral antivirals as monotherapy for active eye disease—topical therapy is essential for corneal disease control 1, 2
- Never prescribe corticosteroids for epithelial disease, even if inflammation appears significant 2
- Do not allow athletes to self-diagnose or deny infection—require pre-competition examination by trained personnel 3
- Topical acyclovir alone is substantially less effective than oral medication and should be avoided 3