A patient tests positive for herpes simplex virus type 1 (HSV‑1); how should this be managed?

Management of HSV-1 Positive Patient

Management depends entirely on whether the patient has symptomatic disease or is simply seropositive without active lesions—asymptomatic HSV-1 seropositivity requires no antiviral treatment, only counseling about transmission risk. 1

Clinical Presentation Assessment

First, determine the clinical scenario:

• Asymptomatic seropositive: No treatment indicated; proceed to counseling only 1
• Active orolabial lesions: Consider episodic or suppressive therapy based on frequency 1, 2
• Active genital lesions: Treat as first episode or recurrent disease 1
• Severe/disseminated disease: Hospitalize for IV acyclovir 1, 2

Treatment Regimens by Clinical Scenario

First Clinical Episode (Oral or Genital)

For first-episode symptomatic HSV-1 infection, initiate oral antiviral therapy for 7-10 days: 1

• Acyclovir 400 mg orally 3 times daily for 7-10 days, OR 1
• Acyclovir 200 mg orally 5 times daily for 7-10 days, OR 1
• Valacyclovir 1 g orally twice daily for 7-10 days, OR 1
• Famciclovir 250 mg orally 3 times daily for 7-10 days 1

Treatment may be extended beyond 10 days if lesions have not completely healed. 1

Recurrent Episodes

Most immunocompetent patients with recurrent HSV-1 do not benefit from episodic treatment and it is generally not recommended. 1 However, if treatment is initiated during prodrome or within 1 day of lesion onset, some patients experience limited benefit. 1

If episodic therapy is chosen: 1

• Acyclovir 400 mg orally 3 times daily for 5 days, OR 1
• Acyclovir 800 mg orally twice daily for 5 days 1

Suppressive Therapy for Frequent Recurrences

For patients with ≥6 recurrences per year, daily suppressive therapy reduces recurrence frequency by at least 75%. 1, 2

• Acyclovir 400 mg orally twice daily 1, 2
• Alternative: Acyclovir 200 mg orally 3-5 times daily (titrate to lowest effective dose) 1

After 1 year of continuous suppressive therapy, discontinue acyclovir to reassess the patient's recurrence rate. 1

Severe Disease Requiring Hospitalization

For severe disease or complications (disseminated infection, encephalitis, pneumonitis, hepatitis), provide IV therapy: 1

• Acyclovir 5-10 mg/kg IV every 8 hours for 5-7 days or until clinical resolution 1, 2
• For HSV encephalitis: Acyclovir 10 mg/kg IV every 8 hours for at least 21 days 1, 2

Special Populations

Immunocompromised Patients

Immunocompromised patients require higher doses and longer treatment duration: 1

• Acyclovir 400 mg orally 3-5 times daily until clinical resolution 1
• For suppression: Acyclovir 400 mg orally 3-5 times daily 1, 2
• Treatment duration: At least 21 days, with reassessment by CSF PCR 1

If lesions persist despite acyclovir therapy, suspect resistance and consider foscarnet 40 mg/kg IV every 8 hours. 1, 2

Pregnant Women

Systemic acyclovir safety is not established in pregnancy; avoid routine use except for life-threatening maternal disease. 1

• For life-threatening maternal HSV infection (disseminated disease, encephalitis, pneumonitis, hepatitis): IV acyclovir is indicated 1
• Do NOT use systemic acyclovir for recurrent episodes or suppressive therapy during pregnancy in non-life-threatening situations 1
• Report any acyclovir use during pregnancy to the registry (1-800-722-9292, ext. 58465) 1

Essential Patient Counseling

Natural History and Transmission

All HSV-1 positive patients require comprehensive counseling regardless of symptom status: 1

• HSV-1 is a chronic, lifelong infection with potential for recurrent episodes 1
• Transmission occurs during both symptomatic AND asymptomatic periods through viral shedding 1
• Genital HSV-1 recurs much less frequently than HSV-2 (median 1.3 recurrences/year in first year, decreasing to 0.7/year in second year; 43% have no recurrence in first year) 3
• HSV-1 genital infection has better prognosis than HSV-2, making viral typing important for counseling 1, 3

Behavioral Recommendations

• Abstain from sexual activity when lesions or prodromal symptoms are present 1
• Use condoms during all sexual exposures with new or uninfected partners 1
• Inform sexual partners about HSV-1 status 1
• Recognize that condoms reduce but do not eliminate transmission risk 1, 4

Special Warnings

• Women of childbearing age must inform obstetric providers about HSV infection due to neonatal transmission risk 1
• The risk of neonatal infection should be explained to all patients, including men 1

Common Pitfalls to Avoid

• Do not treat asymptomatic seropositive patients with antivirals—seropositivity alone is not an indication for therapy 1
• Do not rely on topical acyclovir—it is substantially less effective than oral therapy and its use is discouraged 1, 5
• Do not assume suppressive therapy eliminates transmission risk—it reduces but does not eliminate viral shedding 1
• Do not use commercially available non-type-specific HSV antibody tests—they lack adequate sensitivity and specificity 1
• Do not continue suppressive therapy indefinitely without reassessment—discontinue after 1 year to evaluate ongoing recurrence rate 1

Management of Sexual Partners

Sexual partners should receive evaluation and counseling: 1

• Symptomatic partners: Manage identically to any patient with genital lesions 1
• Asymptomatic partners: Query about typical and atypical genital lesions; encourage self-examination 1
• Most persons with HSV infection lack history of typical lesions and may benefit from counseling even when asymptomatic 1