What treatment is recommended for a recurring oral lesion?

Management of Recurring Oral Herpes Simplex Lesions

For recurring oral herpes lesions (cold sores), initiate oral antiviral therapy immediately at first symptom onset, and strongly consider daily suppressive therapy if experiencing 6 or more recurrences per year. 1

Acute Treatment for Current Lesion

First-Line Oral Antiviral Options

Start treatment immediately at the first sign of symptoms (prodrome) or within 24 hours of lesion appearance for maximum efficacy: 1, 2

• Valacyclovir 2g twice daily for 1 day (most convenient, single-day regimen) 1
• Famciclovir 1500mg as a single dose (alternative single-day option) 1, 3
• Acyclovir 400mg five times daily for 5 days (requires more frequent dosing but effective) 2

Critical Timing Consideration

Peak viral replication occurs within the first 24 hours after lesion onset, making early intervention essential for blocking viral replication and reducing episode duration. 1 Treatment initiated after lesions are fully developed has significantly reduced efficacy. 1

Suppressive Therapy for Frequent Recurrences

Indications for Daily Suppressive Therapy

You should strongly consider chronic suppressive therapy if: 1

• 6 or more recurrences per year (primary indication) 1
• Particularly severe, frequent, or complicated disease 1
• Significant psychological distress from recurrences 1

Suppressive Therapy Regimens

Choose one of the following daily regimens: 1

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

Expected Efficacy

Daily suppressive therapy reduces recurrence frequency by ≥75% among patients with frequent recurrences. 1 However, it reduces but does not eliminate asymptomatic viral shedding. 1

Duration and Monitoring

• Safety and efficacy documented for acyclovir up to 6 years of continuous use 1
• Valacyclovir and famciclovir have documented safety for 1 year of continuous use 1
• After 1 year of continuous suppressive therapy, consider discontinuation to reassess recurrence rate, as frequency naturally decreases over time in many patients 1

Important Clinical Considerations

What NOT to Do

• Do not rely on topical antivirals for treatment or prevention - they cannot reach the site of viral reactivation in nerve ganglia and provide only modest benefit for active lesions 4, 1
• Topical acyclovir is substantially less effective than systemic therapy and should not be used as monotherapy 2

Trigger Avoidance

Counsel patients to identify and avoid personal triggers including: 1

• Ultraviolet light exposure (use sunscreen or zinc oxide) 4
• Fever 1
• Psychological stress 1
• Menstruation 1

Resistance Considerations

• Acyclovir resistance is rare (<0.5%) in immunocompetent patients 1, 5
• If lesions persist despite appropriately dosed antiviral therapy after 7-10 days, suspect drug resistance and obtain viral culture with susceptibility testing 2, 5
• For confirmed acyclovir-resistant HSV, IV foscarnet (40mg/kg IV three times daily) is the treatment of choice 1, 2, 5

Common Pitfalls to Avoid

• Starting treatment too late - efficacy decreases significantly when treatment begins after lesions have fully developed 1
• Failing to consider suppressive therapy in patients with ≥6 recurrences per year who could significantly benefit 1
• Using inadequate dosing - short-course, high-dose therapy is more effective than traditional longer courses with lower doses 4, 1
• Relying solely on topical treatments when oral therapy is substantially more effective 1, 2