Treatment for Herpes Gladiatorum
For acute outbreaks of herpes gladiatorum, treat with oral valacyclovir 500 mg twice daily for 7 days, which reduces viral clearance time by 21% compared to placebo. 1
Acute Episode Management
First-Line Treatment Options
- Valacyclovir 500 mg orally twice daily for 7 days is the preferred regimen based on wrestling-specific data showing significant reduction in mean time to PCR clearance (6.43 days vs 8.14 days with placebo). 1
- Alternative oral antiviral options include acyclovir 400 mg three times daily for 7-10 days, valacyclovir 1 g twice daily for 7-10 days, or famciclovir 250 mg three times daily for 7-10 days. 2
- Initiate treatment within 24 hours of symptom onset for maximum efficacy, as early treatment during prodrome or within 1 day of lesion onset is most effective. 3, 1
Treatment Duration Considerations
- Extend therapy beyond 7-10 days if healing is incomplete at the end of the standard course. 2
- Continue treatment until lesions have completely healed in severe cases. 4
What NOT to Do
- Never use topical acyclovir as it is substantially less effective than oral therapy. 3, 2, 5
- Avoid short-course therapy (1-3 days) as this is inadequate for HSV infections in any population. 4
Suppressive Therapy for Recurrent Outbreaks
Indications for Prophylaxis
- Wrestlers with >2 years history of herpes gladiatorum should receive suppressive therapy during wrestling season, as valacyclovir 500 mg daily completely prevented outbreaks (0% recurrence rate) in this population. 6
- For wrestlers with <2 years disease duration, higher doses may be needed: valacyclovir 1,000 mg daily reduced outbreaks to 8% compared to 21% with 500 mg daily. 6
Suppressive Regimen Options
- Valacyclovir 500-1,000 mg orally once daily during active wrestling season. 6
- Alternative suppressive options include acyclovir 400 mg twice daily or famciclovir 250 mg twice daily. 3, 2
- After 1 year of continuous suppressive therapy, consider discontinuation to reassess recurrence frequency. 3, 2
Severe or Complicated Cases
Immunocompromised Patients
- Start with higher doses: acyclovir 400 mg orally 3-5 times daily until clinical resolution, or IV acyclovir 5 mg/kg every 8 hours for severe disease. 4, 2, 5
- Severe mucocutaneous HSV lesions respond best to initial IV acyclovir, then switch to oral therapy once lesions begin to regress. 4
Treatment Failure and Resistance
- Suspect acyclovir resistance if lesions do not improve within 7-10 days of therapy. 4, 3
- Obtain viral culture and susceptibility testing to confirm resistance. 4
- For proven or suspected resistance, switch to IV foscarnet 40 mg/kg every 8 hours until clinical resolution. 3, 2, 7
- Alternative options for external lesions include topical trifluridine or cidofovir, though prolonged application (21-28 days) may be required. 4
Critical Prevention Measures for Wrestling Programs
Contact Precautions
- Wrestlers must be excluded from skin-to-skin contact until all lesions are completely healed and crusted over. 1, 8
- Avoid contact with lesions to prevent autoinoculation or transmission to other body sites. 2
- Asymptomatic viral shedding can occur, so suppressive therapy is crucial during active competition season. 3, 6
Screening Recommendations
- Military and wrestling programs should implement uniform screening protocols prior to close combat training, as no standardized approach currently exists despite similar transmission risks to collegiate wrestling. 8
- Wrestlers with history of herpes gladiatorum should be identified and offered suppressive therapy before season starts. 6
Monitoring and Follow-Up
- Monitor for complete resolution of lesions at follow-up visits. 2
- If symptoms worsen despite treatment, consider secondary bacterial infection or antiviral resistance. 2
- No routine laboratory monitoring is needed for patients on episodic or suppressive therapy unless substantial renal impairment exists. 4
- For patients on high-dose IV acyclovir, monitor renal function at initiation and once or twice weekly during treatment. 4