What is the recommended treatment for a patient with herpes simplex infection on the face?

Treatment of Herpes Simplex Infection on the Face

For facial herpes simplex (cold sores/herpes labialis), initiate oral valacyclovir 2 grams twice daily for 1 day (12 hours apart) at the earliest symptom of prodrome (tingling, itching, or burning), as this provides the most convenient and effective treatment regimen. 1

First-Line Treatment Options

The treatment approach depends critically on timing and location of the facial HSV infection:

For Herpes Labialis (Cold Sores on Lips/Face)

Preferred oral antiviral regimens (in order of convenience):

• Valacyclovir 2g twice daily for 1 day (12 hours apart) - most convenient, single-day therapy 2, 1
• Famciclovir 1500mg as a single dose - alternative single-dose option 2
• Acyclovir 400mg five times daily for 5 days - requires more frequent dosing but equally effective 2, 3

Critical timing consideration: Treatment must be initiated during the prodromal phase or within 24 hours of lesion onset to achieve optimal benefit, as peak viral titers occur in the first 24 hours after lesion onset 2. Starting therapy during prodrome or within 6 hours of first symptoms may abort lesion development in approximately 42-47% of cases 4.

For HSV Conjunctivitis or Periocular Involvement

When facial HSV involves the eye area, the treatment approach differs significantly:

• Topical ganciclovir 0.15% gel three to five times daily, OR
• Topical trifluridine 1% solution five to eight times daily 5

Plus oral antiviral therapy:

• Acyclovir 200-400mg five times daily, OR
• Valacyclovir 500mg two to three times daily, OR
• Famciclovir 250mg twice daily 5

Critical warning: Topical corticosteroids potentiate HSV infection and should be avoided in active HSV conjunctivitis 5. Neonates with periocular HSV require immediate pediatric consultation due to risk of life-threatening systemic infection 5.

For Severe Intraoral HSV or Gingivostomatitis

• Mild cases: Acyclovir 20mg/kg (maximum 400mg/dose) orally three times daily for 5-10 days 2
• Moderate to severe cases requiring hospitalization: Acyclovir 5-10mg/kg IV three times daily until lesions begin to regress, then switch to oral therapy and continue until complete healing 2

Special Populations and Circumstances

Immunocompromised Patients

Immunocompromised patients experience more prolonged and severe episodes, potentially involving the oral cavity or spreading across the face 2. They require:

• Higher doses: Acyclovir 400mg orally three to five times daily until clinical resolution 6
• Consider IV therapy for severe disease or multi-dermatomal involvement 2
• Higher resistance rates: Acyclovir resistance occurs in 7% of immunocompromised patients versus <0.5% in immunocompetent hosts 2, 7

Acyclovir-Resistant HSV

For confirmed acyclovir-resistant infection (suspect if lesions fail to improve after 7-10 days of appropriate therapy):

• Foscarnet 40mg/kg IV three times daily is the treatment of choice 2, 7
• Topical cidofovir gel 1% applied once daily for 5 consecutive days may be considered as alternative 8
• All acyclovir-resistant strains are also resistant to valacyclovir, and most to famciclovir 8

Suppressive Therapy for Frequent Recurrences

For patients with six or more recurrences per year, daily suppressive therapy reduces recurrence frequency by ≥75% 2:

• Valacyclovir 500mg once daily (can increase to 1000mg once daily for very frequent recurrences) 2
• Acyclovir 400mg twice daily 2
• Famciclovir 250mg twice daily 2

Safety and efficacy documented for acyclovir up to 6 years, and for valacyclovir/famciclovir up to 1 year of continuous use 2. After 1 year of suppressive therapy, consider discontinuation to reassess recurrence frequency 2.

Important Clinical Considerations and Pitfalls

Avoid These Common Mistakes:

1. Do not rely on topical antivirals alone for facial HSV (excluding ocular involvement) - they provide only modest benefit compared to oral therapy and cannot reach the site of viral reactivation 2, 9

2. Do not use topical corticosteroids on active HSV lesions, as they potentiate infection 5

3. Do not delay treatment - efficacy decreases significantly when initiated after lesions have fully developed 2

4. Do not use inadequate dosing - short-course, high-dose therapy (valacyclovir 2g twice daily for 1 day) is more effective than traditional longer courses at lower doses 2

Renal Dose Adjustments

For patients with creatinine clearance <50 mL/min, dosage adjustments are mandatory 1:

• CrCl 30-49 mL/min: Valacyclovir 1g every 12 hours for herpes labialis (do not exceed 1 day of treatment) 1
• CrCl 10-29 mL/min: Valacyclovir 500mg every 12 hours 1
• CrCl <10 mL/min: Valacyclovir 500mg as a single dose 1

Patient Counseling

• Provide patients with a prescription to keep on hand for immediate self-initiation at first symptoms 2
• Advise patients to identify and avoid personal triggers: UV light exposure, fever, psychological stress, menstruation 2
• Recommend sunscreen (SPF 15 or above) or zinc oxide to decrease UV light-triggered recurrences 2, 9
• Counsel that suppressive therapy reduces but does not eliminate asymptomatic viral shedding 2
• Advise abstaining from activities that could transmit virus while lesions are present 2

Follow-Up

For HSV conjunctivitis or periocular involvement, follow-up within 1 week is essential, including interval history, visual acuity measurement, and slit-lamp biomicroscopy 5. For uncomplicated herpes labialis in immunocompetent patients, routine follow-up is not necessary unless lesions fail to improve or worsen, suggesting secondary bacterial infection or antiviral resistance 10.