Treatment of Recurrent HSV-1 Infections
For recurrent HSV-1 infections, initiate oral antiviral therapy with valacyclovir 500 mg twice daily for 5 days or acyclovir 400 mg three times daily for 5 days, starting at the first sign of prodrome or within 24 hours of lesion onset for maximum effectiveness. 1
Treatment Approach: Two Strategies
Episodic Therapy for Recurrent Episodes
Treatment must be initiated during the prodromal period or within 24 hours of lesion onset to achieve meaningful clinical benefit. 1 Delaying treatment beyond 72 hours significantly reduces effectiveness. 1
Recommended episodic regimens include:
- Valacyclovir 500 mg orally twice daily for 5 days 2
- Acyclovir 400 mg orally three times daily for 5 days 2
- Acyclovir 800 mg orally twice daily for 5 days 2
- Acyclovir 200 mg orally five times daily for 5 days 2
- Famciclovir 125 mg orally twice daily for 5 days 2
Patients should be provided with a prescription for antiviral medication to self-initiate at the first sign of recurrence, allowing them to begin treatment immediately without waiting for a medical appointment. 1 This strategy is critical because treatment effectiveness drops dramatically when delayed. 1
Suppressive Therapy for Frequent Recurrences
Daily suppressive therapy should be considered for patients experiencing ≥6 recurrences per year, as it reduces recurrence frequency by ≥75%. 1 This represents a substantial improvement in quality of life for patients with frequent outbreaks. 2
Recommended suppressive regimens include:
- Acyclovir 400 mg orally twice daily 2
- Famciclovir 250 mg orally twice daily 2
- Valacyclovir 250 mg orally twice daily 2
- Valacyclovir 500 mg orally once daily 2
- Valacyclovir 1,000 mg orally once daily 2
Note that valacyclovir 500 mg once daily appears less effective in patients with very frequent recurrences (≥10 episodes per year), so higher dosing regimens should be used in this population. 2
Safety and efficacy have been documented for acyclovir for up to 6 years of continuous use, and for valacyclovir and famciclovir for 1 year. 2 Suppressive therapy has not been associated with emergence of clinically significant acyclovir resistance in immunocompetent patients. 2
After 1 year of continuous suppressive therapy, discontinuation should be discussed with the patient to reassess recurrence frequency, as the natural history of HSV-1 shows decreasing recurrence rates over time in many patients. 2
Critical Clinical Considerations
Common Pitfalls to Avoid
Topical acyclovir should never be used alone, as it is substantially less effective than systemic treatment. 1 This is a common mistake that leads to treatment failure and patient dissatisfaction.
Treatment delayed beyond 72 hours for recurrences should be avoided, as the window for meaningful clinical benefit closes rapidly. 1
Comparative Effectiveness
Valacyclovir and famciclovir are comparable to acyclovir in clinical outcomes. 2 However, valacyclovir and famciclovir offer more convenient dosing schedules, which may improve patient adherence during prolonged treatment. 2
Transmission Counseling
Patients should be counseled that asymptomatic viral shedding occurs less frequently with HSV-1 than HSV-2, but transmission can still occur during asymptomatic periods. 2 Suppressive therapy reduces but does not eliminate asymptomatic viral shedding. 2
Patients should abstain from sexual activity when lesions or prodromal symptoms are present and should inform sexual partners about their HSV-1 infection. 2 Condom use during all sexual exposures with new or uninfected partners should be encouraged. 2
Special Populations
For HIV-infected patients or other immunocompromised individuals with recurrent HSV-1, higher doses and longer treatment courses may be required. 3 Famciclovir 500 mg twice daily for 7 days is an appropriate regimen for HIV-infected patients with recurrent orolabial or genital HSV-1. 3
Renal Impairment
Dosage adjustments are required for patients with renal impairment to prevent acute renal failure, which can occur with higher than recommended doses. 3 Creatinine clearance should guide dose modifications.