Management of Recurrent Oral HSV-1 (Cold Sores)
First-Line Episodic Antiviral Therapy
For occasional recurrent oral HSV-1, initiate episodic treatment with valacyclovir 500 mg orally twice daily for 5 days, starting during the prodrome or within 24 hours of lesion onset. 1
Alternative Episodic Regimens
Acyclovir 400 mg orally three times daily for 5 days is an effective alternative with comparable clinical outcomes but requires more frequent dosing. 1
Famciclovir 125 mg orally twice daily for 5 days offers similar efficacy with convenient twice-daily dosing. 1
All three agents (valacyclovir, acyclovir, famciclovir) are comparable in clinical outcomes; valacyclovir and famciclovir simply offer more convenient dosing schedules than acyclovir. 1
Critical Timing Principles
Treatment must be initiated during the prodromal period or within 24 hours of lesion onset because peak viral replication occurs in the first 24 hours—this timing is essential for blocking viral replication and shortening symptom duration. 1
Delaying treatment beyond 72 hours significantly reduces effectiveness and should be avoided. 1
Patients should receive a prescription for antiviral medication to self-initiate at the first sign of recurrence, as treatment effectiveness depends critically on early initiation. 1
Criteria for Suppressive Therapy
Daily suppressive antiviral therapy should be considered for patients experiencing ≥6 recurrences per year, which reduces recurrence frequency by ≥75%. 1
Recommended Suppressive Regimens
Valacyclovir 500 mg orally once daily is the first-line suppressive regimen for most patients with frequent recurrences. 1
Valacyclovir 250 mg orally twice daily is an alternative suppressive option. 1
For patients with very frequent recurrences (≥10 episodes per year), valacyclovir 500 mg once daily may be less effective—these patients should receive valacyclovir 1000 mg once daily instead. 1, 2
Acyclovir 400 mg orally twice daily is an effective alternative suppressive regimen with documented safety for up to six years of continuous use. 1, 2
Duration and Reassessment
After one year of uninterrupted suppressive therapy, clinicians should consider discontinuing treatment to reassess recurrence frequency, as the number of episodes often decreases over time. 1, 2
Safety and efficacy have been documented for up to one year with valacyclovir and up to six years with acyclovir for continuous suppressive therapy. 1, 2
Additional Clinical Benefits
Suppressive therapy significantly lowers asymptomatic viral shedding and transmission risk, but does not eliminate either completely. 1, 2
In immunocompetent patients, resistance rates remain below 0.5% despite more than two decades of widespread antiviral use. 2
Common Pitfalls to Avoid
Topical acyclovir alone is substantially less effective than systemic antiviral therapy and should not be used as the sole treatment for recurrent oral HSV-1. 1, 3
Patients should be counseled that HSV-1 is a chronic, incurable infection with potential for lifelong recurrence—antiviral medications control symptoms but do not eradicate the virus. 1
Asymptomatic viral shedding occurs less frequently with HSV-1 than HSV-2, but transmission can still occur during asymptomatic periods. 1
Patients should abstain from sexual activity when lesions or prodromal symptoms are present and should inform partners about their HSV-1 infection. 1