Treatment of Recurrent Herpes Simplex on the Nose
For recurrent HSV lesions on the nose, initiate episodic oral antiviral therapy with valacyclovir 500 mg twice daily for 5 days, starting at the first sign of prodromal symptoms or within 24 hours of lesion onset. 1
First-Line Episodic Treatment Options
The CDC recommends the following oral regimens for recurrent HSV-1 infections (which typically affect the face, including the nose):
- Valacyclovir 500 mg orally twice daily for 5 days (preferred for convenience) 1
- Acyclovir 400 mg orally three times daily for 5 days 1
- Famciclovir 125 mg orally twice daily for 5 days 1
All three options are comparable in clinical outcomes, but valacyclovir and famciclovir offer more convenient dosing schedules than acyclovir 1
Critical Timing for Maximum Effectiveness
Treatment must be initiated during the prodromal period (tingling, itching, burning) or within 24 hours of lesion onset to achieve maximum benefit. 1 Delaying treatment beyond 72 hours significantly reduces effectiveness 1
Provide the patient with a prescription to self-initiate treatment at the first sign of recurrence rather than waiting for an office visit 1 This patient-initiated approach is explicitly recommended by the CDC and dramatically improves outcomes 1
When to Consider Suppressive Therapy
If the patient experiences ≥6 recurrences per year, switch from episodic to daily suppressive therapy 1
Suppressive therapy options for HSV-1:
- Valacyclovir 500 mg orally once daily 1
- Valacyclovir 250 mg orally twice daily 1
- Note: Valacyclovir 500 mg once daily may be less effective in patients with ≥10 episodes per year 1
Suppressive therapy reduces recurrence frequency by ≥75% 1, 2
Critical Pitfalls to Avoid
- Never use topical acyclovir alone - it is substantially less effective than systemic oral therapy 1, 2
- Do not delay prescribing episodic medication until an outbreak occurs - patients need a prescription in hand to self-initiate immediately 1
- Do not wait more than 24-72 hours after lesion onset to start treatment - efficacy drops dramatically after this window 1, 3
Patient Counseling Essentials
Inform the patient that:
- HSV-1 is a chronic, lifelong infection with potential for recurrence 1
- Asymptomatic viral shedding can occur, though less frequently with HSV-1 than HSV-2 1
- They should abstain from close contact when lesions or prodromal symptoms are present 1
- Treatment controls symptoms but does not eradicate the virus 2
Special Considerations
If lesions do not begin to resolve within 7-10 days of therapy, suspect acyclovir resistance (rare in immunocompetent patients) and consider foscarnet 40 mg/kg IV every 8 hours as an alternative 2, 4