What is the recommended treatment for herpes?

Treatment for Herpes

Oral antiviral medications—acyclovir, valacyclovir, or famciclovir—are the cornerstone of herpes treatment, with specific regimens depending on whether you're treating genital herpes, oral herpes (cold sores), or herpes zoster (shingles). 1, 2

Treatment by Herpes Type

Genital Herpes

Initial Episode:

• Valacyclovir 1 gram twice daily for 10 days is the preferred first-line treatment, most effective when started within 48 hours of symptom onset 3
• Alternative: Acyclovir 400 mg three times daily for 7-10 days 1
• Alternative: Famciclovir at appropriate doses for 7-10 days 2

Recurrent Episodes:

• Valacyclovir 500 mg twice daily for 3 days offers the most convenient short-course option 3
• Alternative: Acyclovir 400 mg three times daily for 5 days, or 800 mg twice daily for 5 days 1
• Alternative: Famciclovir 125 mg twice daily for 5 days 1
• Treatment must be initiated at the first sign of prodrome or within 24 hours of lesion onset for maximum benefit 2, 3

Suppressive Therapy (for ≥6 recurrences per year):

• Valacyclovir 500-1000 mg once daily provides the most convenient once-daily dosing 1, 2, 3
• Alternative: Acyclovir 400 mg twice daily 1, 2
• Alternative: Famciclovir 250 mg twice daily 1, 2
• Daily suppressive therapy reduces recurrence frequency by ≥75% 1, 2
• Safety documented for acyclovir up to 6 years; valacyclovir and famciclovir for 1 year 1, 2
• After 1 year of continuous therapy, consider discontinuation to reassess recurrence rate, as frequency naturally decreases over time 1, 2

Oral Herpes (Cold Sores/Herpes Labialis)

Episodic Treatment:

• Valacyclovir 2 grams twice daily for 1 day (two doses 12 hours apart) is the most convenient and effective regimen 2, 3
• Alternative: Famciclovir 1500 mg as a single dose 2
• Alternative: Acyclovir 400 mg five times daily for 5 days (requires more frequent dosing) 2
• Treatment reduces episode duration by approximately 1 day when initiated during prodrome 2, 3
• Peak viral titers occur within the first 24 hours, making early treatment critical 1, 2

Suppressive Therapy (for frequent cold sores):

• Valacyclovir 500 mg once daily (increase to 1000 mg for very frequent recurrences) 2
• Alternative: Acyclovir 400 mg twice daily 2
• Alternative: Famciclovir 250 mg twice daily 2

Oral Herpetic Gingivostomatitis

Mild Cases:

• Acyclovir 400 mg (or 20 mg/kg, maximum 400 mg/dose) three times daily for 5-10 days 2, 4

Moderate to Severe Cases:

• IV acyclovir 5-10 mg/kg every 8 hours until lesions begin to regress, then switch to oral therapy and continue until complete healing 2, 4

Herpes Zoster (Shingles)

Standard Treatment:

• Valacyclovir 1 gram three times daily for 7-10 days offers convenient dosing 5, 3
• Alternative: Acyclovir 800 mg five times daily for 7-10 days 5
• Alternative: Famciclovir 500 mg three times daily for 7-10 days 5
• Treatment must be initiated within 72 hours of rash onset for optimal efficacy in reducing acute pain and preventing postherpetic neuralgia 5
• Continue treatment until all lesions have completely scabbed, not just for an arbitrary 7-day period 5

Severe or Complicated Cases (disseminated, CNS involvement, immunocompromised patients):

• IV acyclovir 10 mg/kg every 8 hours for minimum 7-10 days and until clinical resolution 5
• Consider temporary reduction in immunosuppressive medications if applicable 5

Special Populations

HIV-Infected Patients

• Use standard oral doses but extend duration to 7-14 days for oral herpes 4
• For genital herpes suppression: Valacyclovir 500 mg twice daily (if CD4+ ≥100 cells/mm³) 1, 3
• Avoid short-course (1-3 day) therapy 4

Immunocompromised Patients

• Episodes are typically longer and more severe 2
• May require higher doses or extended treatment duration 5
• Consider IV therapy for severe presentations 5
• Resistance rates are higher (acyclovir 7% vs <0.5% in immunocompetent patients) 1, 2

Renal Impairment

• Dose adjustment is mandatory to prevent acute renal failure 2, 4
• Reduce frequency based on creatinine clearance 2

Acyclovir-Resistant Cases

• Foscarnet 40 mg/kg IV three times daily is the treatment of choice 2, 5
• Resistance remains rare (<0.5% in immunocompetent hosts) 1, 2

Critical Timing Considerations

Treatment is most effective when initiated:

• During the prodromal phase (tingling, itching, burning) 2, 3
• Within 24 hours of symptom onset for oral herpes 2, 4
• Within 48 hours for genital herpes initial episodes 3
• Within 72 hours for herpes zoster 5

Peak viral replication occurs in the first 24 hours, making early intervention essential for blocking viral replication and reducing episode severity 1, 2.

Common Pitfalls to Avoid

• Do not rely on topical antivirals as primary therapy—they are substantially less effective than oral agents and cannot reach sites of viral reactivation 1, 2, 4
• Do not delay treatment initiation—waiting until lesions fully develop significantly reduces efficacy 2, 4
• Do not use inadequate dosing—short-course, high-dose therapy is more effective than traditional longer courses with lower doses 2
• Do not fail to consider suppressive therapy in patients with ≥6 recurrences per year who could significantly benefit 1, 2
• Do not forget renal dose adjustments in patients with impaired kidney function 2, 4

Patient Counseling

• Explain the natural history of disease with emphasis on potential for recurrent episodes and asymptomatic viral shedding 1
• Advise abstinence from sexual activity when lesions or prodromal symptoms are present 1
• Encourage condom use during all sexual exposures, as transmission can occur during asymptomatic periods 1
• Discuss identifying and avoiding personal triggers (UV light, stress, fever, menstruation) 2
• Inform childbearing-aged women to notify healthcare providers during pregnancy about HSV infection 1

Adverse Effects

Common side effects are typically mild to moderate and include 2, 4:

• Headache (<10%)
• Nausea (<4%)
• Diarrhea

No routine laboratory monitoring is needed for episodic or suppressive therapy unless significant renal impairment exists 4.