What is the appropriate treatment for a patient with herpes simplex infection manifesting as blisters on the eyelid and a cold sore on the lip, accompanied by nasal congestion?

Treatment for Herpes Simplex Periocular Infection with Concurrent Labial Lesions

This patient requires immediate oral antiviral therapy with either valacyclovir 500 mg three times daily or acyclovir 400 mg five times daily for 7-10 days, combined with topical antiviral therapy (ganciclovir 0.15% gel three to five times daily or trifluridine 1% solution five to eight times daily) to prevent progression of the periocular HSV infection. 1, 2

Rationale for Aggressive Treatment

• Oral antivirals alone are insufficient for HSV blepharoconjunctivitis - the American Academy of Ophthalmology explicitly states that oral antiviral monotherapy may not adequately prevent progression of HSV periocular disease, and the addition of topical antiviral treatment is necessary for effective management 1, 2

• The presence of vesicular lesions on the eyelid extending to the eyebrow with one ruptured blister indicates active HSV replication in the periocular region, which poses risk for corneal involvement and vision-threatening complications 1

Specific Treatment Regimen

Oral Antiviral Options (Choose One):

• Valacyclovir 500 mg orally three times daily for 7-10 days or until complete clinical resolution 1, 2, 3
• Acyclovir 400 mg orally five times daily for 7-10 days or until complete clinical resolution 1, 2
• Famciclovir 250 mg orally twice daily as an alternative 1, 2

Topical Antiviral (Required in Addition):

• Ganciclovir 0.15% gel applied three to five times daily (preferred due to less ocular surface toxicity) 1, 2
• Trifluridine 1% solution five to eight times daily (alternative, but causes epithelial toxicity if used beyond 2 weeks) 1, 2

Critical Management Points

What to Avoid:

• Never use topical corticosteroids - they potentiate HSV infection and are absolutely contraindicated in active HSV periocular disease 1
• Do not rely on topical antivirals alone - they are substantially less effective than combination therapy 2

Concurrent Labial Herpes Management:

• The same oral antiviral regimen treats both the periocular and labial lesions simultaneously 1, 3
• For the cold sore specifically, valacyclovir is FDA-approved at 2 grams twice daily for one day for herpes labialis, but given the periocular involvement, the longer 7-10 day course is required 3

Nasal Congestion Consideration

• The clear nasal congestion with clear lung sounds likely represents a concurrent viral upper respiratory infection or is related to the HSV reactivation trigger 1
• This does not alter the HSV treatment approach but may explain the viral reactivation (as URIs are common HSV triggers) 1

Follow-Up Requirements

• Mandatory ophthalmology evaluation within 1 week to assess for corneal involvement through slit-lamp biomicroscopy and visual acuity measurement 1, 2
• Earlier follow-up (within 2-3 days) is warranted if the patient develops eye pain, photophobia, decreased vision, or worsening symptoms 1
• Monitor for corneal epithelial ulceration, which would indicate progression to HSV keratitis requiring more intensive management 1

Long-Term Prophylaxis Consideration

• Given the patient's history of recurrent HSV since childhood with seasonal exacerbations, consider suppressive therapy with lower-dose oral antivirals (acyclovir 400 mg twice daily or valacyclovir 500 mg once daily) during winter months to prevent future recurrences 1, 3, 4
• Suppressive therapy reduces HSV recurrence frequency by at least 75% in patients with frequent recurrences 1

Special Warnings

• If the patient is immunocompromised (HIV, transplant, chemotherapy), more aggressive therapy with higher doses and longer duration is required, potentially including intravenous acyclovir 5-10 mg/kg every 8 hours 2, 5
• Treatment must be initiated promptly - efficacy decreases significantly when started more than 72 hours after symptom onset 1, 3