Treatment for HSV Flare-Up
For recurrent HSV flare-ups, treat with oral valacyclovir 500 mg twice daily for 5 days, initiated at the first sign of prodrome or within 24 hours of lesion onset. 1, 2, 3
First-Line Treatment Options for Recurrent Episodes
The CDC recommends several equivalent oral antiviral regimens for recurrent HSV episodes, all administered for 5 days: 4, 1, 2, 3
- Valacyclovir 500 mg twice daily (preferred due to convenient dosing) 2, 3
- Acyclovir 400 mg three times daily 1, 2, 3
- Acyclovir 800 mg twice daily 1, 2, 3
- Famciclovir 125 mg twice daily 2, 3
Timing is critical: Treatment must be started during the prodrome or within 1 day of lesion onset to achieve maximum benefit. 2, 3 When initiated early, these regimens reduce lesion duration from a median of 6 days to 4 days and decrease viral shedding time from approximately 58 hours to 25 hours. 5
When to Consider Suppressive Therapy
If you experience 6 or more recurrences per year, switch to daily suppressive therapy rather than episodic treatment. 1, 2, 3 Suppressive therapy reduces recurrence frequency by at least 75% and decreases asymptomatic viral shedding. 4, 1, 3
Recommended suppressive regimens include: 1, 2, 3
- Valacyclovir 1 gram once daily (most convenient)
- Valacyclovir 500 mg once daily (alternative)
- Acyclovir 400 mg twice daily
- Famciclovir 250 mg twice daily
Suppressive therapy is safe for up to 6 years with acyclovir and at least 1 year with valacyclovir. 2 After 1 year of continuous suppression, consider discontinuing to reassess your natural recurrence frequency. 4, 2
Special Populations and Situations
Immunocompromised Patients
If you are HIV-infected or otherwise immunocompromised, use higher doses and longer treatment duration: acyclovir 400 mg orally 3-5 times daily for 5-14 days, or consider intravenous therapy for severe disease. 1, 3 These patients may experience prolonged episodes with extensive disease and are at higher risk for acyclovir-resistant strains. 4
Severe Disease Requiring Hospitalization
For severe HSV disease or complications, administer intravenous acyclovir 5-10 mg/kg every 8 hours for 5-7 days or until clinical improvement. 1, 3
Acyclovir-Resistant HSV
If lesions fail to improve within 7-10 days of appropriate antiviral therapy, suspect acyclovir resistance. 2, 6 In this case, switch to foscarnet 40 mg/kg IV three times daily or 60 mg/kg IV twice daily as the treatment of choice. 1, 6 Resistance is rare in immunocompetent patients but occurs more frequently in immunocompromised hosts with frequent, severe reactivations. 6
Critical Pitfalls to Avoid
Never use topical acyclovir - it is substantially less effective than oral therapy and is strongly discouraged by the CDC. 2, 3
Do not delay treatment - the benefit of episodic therapy is maximized only when started during prodrome or within 1 day of lesion onset. 2, 3 Most immunocompetent patients with recurrent disease receive limited benefit if treatment is delayed beyond this window. 4
Avoid valacyclovir 8 grams per day in immunocompromised patients due to risk of hemolytic uremic syndrome/thrombotic thrombocytopenic purpura. 2
Patient Counseling Points
- HSV is a chronic, incurable viral infection with potential for recurrent episodes
- Antiviral medications control symptoms but do not eradicate latent virus
- Asymptomatic viral shedding can occur, allowing transmission even without visible lesions
- Abstain from sexual activity when lesions or prodromal symptoms are present
- Use condoms consistently during all sexual exposures with new or uninfected partners
- Inform sexual partners about HSV status
Monitoring Requirements
No laboratory monitoring is needed for patients on episodic or suppressive therapy unless substantial renal impairment is present. 3 Acyclovir is primarily renally excreted and requires dose adjustment in renal insufficiency. 1