Treatment of Recurrent Herpes Simplex in Healthy Adults
For an otherwise healthy adult with a recurrent herpes simplex outbreak, oral valacyclovir 2 grams twice daily for 1 day is the recommended first-line treatment, which reduces healing time by approximately one day. 1
Treatment Algorithm for Recurrent Episodes
First-Line Oral Antiviral Options
The most effective approach is to initiate treatment during the prodrome or within the first 24 hours of lesion onset, as peak viral titers occur in the first 24 hours when most lesions are vesicular 2:
- Valacyclovir 2 grams twice daily for 1 day (preferred for convenience and efficacy) 1
- Acyclovir 400 mg orally 5 times daily for 5 days 2, 3
- Acyclovir 800 mg orally twice daily for 5 days 2, 3
- Acyclovir 200 mg orally 5 times daily for 5 days 2, 3
Why Oral Over Topical
Topical antiviral agents are substantially less effective than oral medications and their use is discouraged. 2, 1, 3 Topical therapy provides only minimal clinical benefit compared to systemic treatment 2. Topical penciclovir reduces lesion duration by only approximately half a day compared to placebo 4, which is inferior to oral options.
When to Consider Suppressive Therapy
For patients experiencing frequent recurrences (≥6 episodes per year), daily suppressive therapy should be offered 1, 5:
- Acyclovir 400 mg orally twice daily 2
- Valacyclovir 500 mg to 1 gram daily 5
- Famciclovir (alternative option) 2
Suppressive therapy reduces recurrence frequency by at least 75% 2. After 1 year of continuous suppressive therapy, discontinuation should be considered to reassess the patient's natural recurrence rate 2.
Important Clinical Pitfalls
Timing is Critical
Treatment must be initiated as soon as possible—ideally within 1 hour of symptom onset—to ensure optimal therapeutic benefit, as the natural healing process begins within the first 24 hours 2, 4. Most immunocompetent patients with recurrent disease do not benefit significantly from acyclovir treatment if initiated after 2 days of lesion onset 2.
Chronic Therapy Not Required
Chronic therapy with acyclovir is not required after lesions resolve unless the patient has frequent or severe recurrences 2. Acute episodes can be treated successfully with short courses 2.
Resistance Considerations
Acyclovir-resistant HSV strains are rare in immunocompetent patients 6. If lesions do not resolve within 7-10 days of appropriately dosed antiviral therapy, viral culture and susceptibility testing should be obtained 7. For confirmed resistance, intravenous foscarnet or cidofovir can be used 2.
Prevention Strategies
- Sunscreen application (SPF 15 or above) can effectively prevent recurrent herpes labialis triggered by UV light exposure 5
- Avoid sexual contact when herpetic lesions are evident 2
- Patients should be counseled that recurrences may be triggered by UV light, fever, stress, or menstruation 2
Special Populations
Pregnant Women
Acyclovir prophylaxis during late pregnancy for frequent, severe recurrences may be indicated, though routine prophylaxis is not recommended 2. No pattern of adverse pregnancy outcomes has been reported with acyclovir exposure 2.
Immunocompromised Patients
These patients may require longer courses of therapy and experience more prolonged episodes with extensive disease 2, 1, 7. Healing is slower and treatment failures occur more frequently 7. Close monitoring is essential 1, 3.