Can This Patient Start Valtrex and Low-Dose Steroids?

Yes, start valacyclovir immediately for the cold sores, but do NOT add systemic corticosteroids for the sore throat. 1, 2

Valacyclovir for Cold Sores: Strongly Recommended

Initiate valacyclovir 2g twice daily for 1 day (two doses, 12 hours apart) for the active cold sores on the lower lip 3, 1, 2
Treatment should be started immediately, even though lesions have already developed, as valacyclovir remains effective when initiated during active outbreak 2, 4
This high-dose, short-duration regimen reduces episode duration by approximately 1 day and accelerates healing 1, 4

The FDA specifically approves valacyclovir for treatment of cold sores (herpes labialis) in adults 2
Multiple cold sores indicate active HSV reactivation requiring antiviral therapy 3
Early treatment during prodrome is ideal, but therapy remains beneficial even after lesion development 2, 4

Given this patient has experienced recurrent outbreaks (initial symptoms 3 days ago, now multiple cold sores), consider long-term suppressive therapy with valacyclovir 500mg once daily if recurrences are frequent (≥6 per year) 3
Suppressive therapy reduces recurrence frequency by ≥75% in patients with frequent outbreaks 3

No guideline or FDA approval supports adding systemic corticosteroids to antiviral therapy for herpes infections 1
Corticosteroids can suppress immune response and potentially worsen viral replication, which is particularly concerning in active HSV infection 1
The 2012 European guideline on acute sore throat states that corticosteroids in conjunction with antibiotic therapy are not routinely recommended and should only be considered in adult patients with severe bacterial pharyngitis (3-4 Centor criteria) receiving antibiotics 5

Both strep tests are negative, ruling out Group A streptococcal pharyngitis 5
The sore throat is likely viral (possibly related to HSV given the cold sores, or another viral URI given the cough, headaches, and drainage) 5
Corticosteroids are specifically contraindicated when HSV infection is present, as they potentiate viral replication 5

Use ibuprofen or acetaminophen for symptomatic relief of sore throat pain 5
These analgesics are the recommended first-line treatment for acute sore throat symptoms 5
Maintain adequate hydration 2
The pharyngitis will likely resolve as the viral illness runs its course 5

The tonsil stone noted on exam is likely incidental and unrelated to current symptoms 5
Swollen lymph nodes are consistent with viral infection (HSV or concurrent viral URI) 5
If sore throat worsens significantly or persists beyond 2-3 weeks, re-evaluate for other causes 5

Valacyclovir is well-tolerated with minimal adverse events; most common side effects include headache (<10%), nausea (<4%), and diarrhea 3, 1
No serious adverse events have been reported in immunocompetent patients at standard doses 1

Do not add systemic steroids to antiviral therapy for herpes labialis - this is not evidence-based and may worsen viral infection 1
Do not rely on topical antivirals alone, as oral therapy is significantly more effective 3
Do not prescribe antibiotics for this viral pharyngitis with negative strep testing 5

Valacyclovir is not a cure for cold sores; recurrences may occur 2
Avoid triggers such as UV light exposure, stress, and fever 3
HSV can be transmitted even without visible lesions through asymptomatic viral shedding 2
If recurrences are frequent (≥6 per year), discuss suppressive therapy at follow-up 3