Dermatologic Manifestations of Herpes Simplex Medication
- Author: Joseph S Eastern, MD; Chief Editor: William D James, MD more...
Acyclovir is an analog of 2'-deoxyguanosine and, along with other nucleoside analogs listed below, remains the drug of choice for herpes simplex virus (HSV) infections. Antibiotics may be used if a secondary bacterial infection develops.
Nucleoside analogs are initially phosphorylated by viral thymidine kinase to eventually form a nucleoside triphosphate. These molecules inhibit HSV DNA polymerase with 30-50 times the potency of human alpha-DNA polymerase.
Acyclovir inhibits the activity of both HSV-1 and HSV-2. Patients experience less pain and faster resolution of cutaneous lesions when topical acyclovir is used within 48 hours from rash onset. It may prevent recurrent outbreaks. Acyclovir has been proven to be safe and effective in preventing neonatal HSV and in eliminating the need for cesarean deliveries.
Penciclovir topical formulation is for use in mild recurrent herpes labialis. It is an inhibitor of DNA polymerase in HSV-1 and HSV-2 strains, inhibiting viral replication.
Famciclovir is a prodrug that when biotransformed into its active metabolite, penciclovir, may inhibit viral DNA synthesis/replication.
Valacyclovir is a prodrug that is rapidly converted to the active drug, acyclovir. Valacyclovir is more expensive but has a more convenient dosing regimen than acyclovir.
Foscarnet is an organic analog of inorganic pyrophosphate that inhibits the replication of known herpesviruses, including CMV, HSV-1, and HSV-2. It inhibits viral replication at the pyrophosphate-binding site on virus-specific DNA polymerases. Poor clinical response or persistent viral excretion during therapy may be due to viral resistance. Patients who can tolerate foscarnet well may benefit from initiation of a maintenance dose of 120 mg/kg/d early in treatment. Individualize dosing based on renal function status.
Cidofovir is approved for the treatment of CMV retinitis. A compounded cream/gel (not FDA approved but recommended by CDC) formulation can be used for localized acyclovir-resistant HSV.
Docosanol cream 10% is used for HSV-1 infections. It prevents viral entry and replication at the cellular level. It should be used at the first sign of a cold sore or fever blister.
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