What is the recommended dose and duration of valtrex (valacyclovir) for an immunocompetent patient with normal renal function presenting with herpes simplex virus type 1 (HSV-1) in the nasal area?

Treatment of Herpes Simplex Virus in the Nasal Area

For an immunocompetent patient with normal renal function presenting with HSV-1 in the nasal area (herpes labialis), take valacyclovir 2 grams twice daily for 1 day (two doses 12 hours apart), starting at the earliest symptom. 1

Dosing Regimen

The FDA-approved dosing for cold sores/herpes labialis is straightforward:

• Valacyclovir 2 grams twice daily for 1 day (total of 2 doses, 12 hours apart) 1
• Initiate therapy at the earliest symptom (tingling, itching, or burning) 1
• This short-course, high-dose regimen is more convenient than traditional longer courses and improves patient adherence 2

Critical Timing Considerations

Treatment must be initiated during the prodromal phase or within 24 hours of symptom onset for optimal efficacy. 2

• Peak viral titers occur in the first 24 hours after lesion onset, making early intervention essential for blocking viral replication 2
• Efficacy decreases significantly when treatment is initiated after lesions have fully developed 2
• Patient-initiated episodic therapy at first symptoms may even prevent lesion development in some cases 2

Alternative Dosing Options

If the 1-day high-dose regimen is not suitable, alternative FDA-approved options include:

• Acyclovir 400 mg five times daily for 5 days 1, 2
• Famciclovir 1500 mg as a single dose 2

However, the valacyclovir 2-gram twice-daily regimen offers superior convenience with proven efficacy. 2

Special Considerations for Nasal/Facial Location

While the nasal area is still considered herpes labialis, facial involvement requires particular attention:

• Monitor for potential spread to adjacent areas 3
• Counsel patients to avoid touching lesions and practice good hand hygiene 2
• Advise patients to avoid contact with susceptible individuals (especially immunocompromised persons, pregnant women, and infants) until lesions have completely crusted 3

When to Consider Extended or Alternative Therapy

If lesions persist after 7-10 days of appropriate valacyclovir treatment, consider HSV resistance. 4

• Resistance rates in immunocompetent patients remain very low (<0.5%) 4, 5
• For confirmed acyclovir-resistant HSV, IV foscarnet (40 mg/kg every 8 hours) is the treatment of choice 4, 6
• All acyclovir-resistant strains are also resistant to valacyclovir 4

Suppressive Therapy for Frequent Recurrences

For patients experiencing 6 or more recurrences per year, consider daily suppressive therapy with valacyclovir 500 mg once daily. 2

• Daily suppressive therapy reduces recurrence frequency by ≥75% 2
• Safety and efficacy documented for up to 1 year with valacyclovir 4
• After 1 year of continuous suppressive therapy, consider discontinuation to reassess recurrence frequency 4, 2

Common Pitfalls to Avoid

• Do not rely on topical antivirals - they provide only modest clinical benefit and are less effective than oral therapy 2
• Do not delay treatment - waiting until lesions are fully developed significantly reduces efficacy 2
• Do not use inadequate dosing - the short-course, high-dose therapy (2 grams twice daily for 1 day) is more effective than traditional longer courses at lower doses 2

Preventive Counseling

Patients should identify and avoid personal triggers: 2

• Ultraviolet light exposure (recommend sunscreen or zinc oxide application)
• Fever
• Psychological stress
• Menstruation (in women)