What is the recommended treatment for a herpes outbreak?

Treatment of Herpes Outbreak

For herpes outbreaks, oral antiviral therapy with valacyclovir, famciclovir, or acyclovir is the recommended treatment, with specific regimens depending on the type and location of herpes infection.

Treatment by Herpes Type

Herpes Labialis (Cold Sores)

First-line treatment is short-course, high-dose oral antiviral therapy initiated at the earliest symptom (tingling, itching, or burning):

• Valacyclovir 2 grams twice daily for 1 day (12 hours apart) 1
• Famciclovir 1500 mg as a single dose 2
• Acyclovir 400 mg five times daily for 5 days (requires more frequent dosing) 3

Critical timing: Treatment must be initiated during the prodromal phase or within 24 hours of symptom onset for maximum efficacy 3. Peak viral titers occur in the first 24 hours after lesion onset, making early intervention essential 3.

Efficacy: Oral antiviral therapy decreases outbreak duration and associated pain by approximately 1 day compared to placebo 4. Famciclovir 1500 mg single dose significantly reduced time to healing of primary lesions (6.2 days vs 6.6 days placebo, p<0.001) and time to return to normal skin (2.9 days vs 4.5 days placebo, p<0.001) 4.

Genital Herpes

First Clinical Episode

Recommended regimens (7-10 days):

• Acyclovir 400 mg orally three times daily 4, 5
• Acyclovir 200 mg orally five times daily 4, 5
• Famciclovir 250 mg orally three times daily 4, 5
• Valacyclovir 1 gram orally twice daily 4, 5, 1

Treatment may be extended if healing is incomplete after 10 days 4, 5.

Therapy is most effective when administered within 48 hours of onset of signs and symptoms 1.

Recurrent Episodes (Episodic Therapy)

Recommended regimens:

• Valacyclovir 500 mg twice daily for 3 days 1, 5
• Acyclovir 400 mg three times daily for 5 days 4, 5
• Acyclovir 800 mg twice daily for 5 days 4, 5
• Acyclovir 200 mg five times daily for 5 days 4, 5
• Famciclovir 125 mg twice daily for 5 days 4, 5
• Famciclovir 1000 mg twice daily for 1 day 2

Treatment should be initiated at the first sign of prodrome or within 1 day after onset of lesions 4, 5. Patients should be provided with medication or a prescription to initiate treatment immediately at first symptoms 4, 5.

Suppressive Therapy (for ≥6 recurrences per year)

Recommended regimens:

• Valacyclovir 1 gram once daily (or 500 mg once daily for patients with ≤9 recurrences/year) 1, 5
• Acyclovir 400 mg twice daily 4, 5
• Famciclovir 250 mg twice daily 4, 5, 2

Efficacy: Daily suppressive therapy reduces recurrence frequency by ≥75% 4, 5. Safety and efficacy documented for acyclovir for up to 6 years, and for valacyclovir and famciclovir for 1 year 4, 5.

After 1 year of continuous suppressive therapy, consider discontinuation to reassess recurrence frequency, as it decreases over time in many patients 4, 5.

Herpes Zoster (Shingles)

Recommended regimen:

• Valacyclovir 1 gram three times daily for 7 days 1
• Famciclovir 500 mg every 8 hours for 7 days 2
• Acyclovir 800 mg five times daily for 7-10 days 6

Therapy should be initiated within 72 hours of rash onset for optimal efficacy 6, 2. Treatment should continue until all lesions have scabbed, not just for an arbitrary 7-day period 6.

Special Populations

HIV-Infected Patients

For recurrent orolabial or genital herpes:

• Famciclovir 500 mg twice daily for 7 days 2, 5
• Valacyclovir 500 mg twice daily (for suppressive therapy in patients with CD4+ ≥100 cells/mm³) 1

Higher doses or longer treatment durations may be required 5.

Immunocompromised Patients

For severe, disseminated, or invasive herpes infections:

• Intravenous acyclovir 5-10 mg/kg every 8 hours 6, 5
• Consider temporary reduction in immunosuppressive medications 6

Acyclovir resistance rates are higher in immunocompromised patients (7% vs <0.5% in immunocompetent patients) 3. For confirmed acyclovir-resistant HSV, foscarnet 40 mg/kg IV three times daily is the treatment of choice 6, 3.

Important Clinical Considerations

Topical antiviral therapy is substantially less effective than oral therapy and is not recommended 4, 6, 5. Topical antivirals provide only modest clinical benefit and do not impact the host immune response 4.

Oral antivirals are superior to topical agents: Oral antiviral therapy offers greater convenience, improved patient adherence with short-course high-dose regimens, and better efficacy 4.

Antiviral medications control symptoms but do not eradicate latent virus or prevent all recurrences 6, 5. Suppressive treatment reduces but does not eliminate asymptomatic viral shedding 4, 5.

Common Pitfalls to Avoid

• Starting treatment too late: Efficacy decreases significantly when treatment is not initiated during prodrome or within 24-72 hours of symptom onset 3, 1, 2
• Relying on topical treatments: Topical antivirals are substantially less effective than oral therapy 4, 6, 5
• Inadequate dosing: Using lower doses appropriate for genital herpes when treating herpes zoster or herpes labialis 6
• Stopping treatment prematurely: For herpes zoster, treatment should continue until all lesions have scabbed, not just for 7 days 6
• Not considering suppressive therapy: Patients with ≥6 recurrences per year significantly benefit from daily suppressive therapy 4, 3, 5

Renal Impairment

Dose adjustments are mandatory for patients with renal impairment to prevent acute renal failure 2. Specific adjustments vary by medication and creatinine clearance 3, 2.

Patient Counseling

Patients should be counseled about:

• The natural history of herpes infections, including potential for recurrent episodes and asymptomatic viral shedding 4, 5
• Abstaining from sexual activity when lesions or prodromal symptoms are present 4, 5
• Using condoms during all sexual exposures with new or uninfected partners 4, 5
• Informing sex partners about having herpes 4, 5
• Identifying and avoiding personal triggers (UV light exposure, stress, fever, menstruation) 3