eMedicine Specialties > Dermatology > Viral Infections
Herpes Simplex: Treatment & Medication
Updated: Aug 25, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
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Treatment
Medical Care
- Most herpes simplex virus (HSV) infections are self-limited. However, antiviral therapy shortens the course of the symptoms and may prevent dissemination and transmission.
- Intravenous, oral, and topical antiviral medications are available for treatment of HSV and are most effective if used at the onset of symptoms. Oral therapy can be given at the time of the episode or as chronic suppressive therapy.
- Treatment of herpes labialis and herpes genitalis generally consists of episodic courses of oral acyclovir, its prodrug valacyclovir, and famciclovir. Oral antiviral medications, acyclovir, valacyclovir, and famciclovir, may be used (off label) as therapy for other uncomplicated HSV conditions (eg, herpes whitlow), and the same doses as those used for herpes genitalis treatment are commonly recommended.
- Commercially available topical treatments for herpes are much less effective than oral therapy.
- Complicated HSV infections, cutaneous and/or visceral dissemination, neonatal HSV, and severe infections in those who are immunocompromised should promptly be treated with intravenous acyclovir.
- In patients who are immunocompromised and have recurrent HSV infections, acyclovir-resistant HSV strains have been identified, and treatment with intravenous foscarnet or cidofovir may be used. Topical foscarnet use has also been reported.
Consultations
Consult a dermatologist and an infectious diseases specialist in cases of complicated or acyclovir-resistant infections.
Activity
Avoidance of known triggers of HSV recurrences, such as UV light and smoking, may diminish the number of outbreaks experienced by an individual.
Medication
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.
Antiviral agents
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 (Zovirax)
Inhibits activity of both HSV-1 and HSV-2. Patients experience less pain and faster resolution of cutaneous lesions when used within 48 h from rash onset. May prevent recurrent outbreaks.
Has been proven to be safe and effective in preventing neonatal HSV and in eliminating the need for cesarean deliveries.
Adult
Topical for herpes labialis: 5% ointment 5 times/d for 5 d
Primary HSV infections: 200 mg PO 5 times/d for 10 d or 5 mg/kg/d IV q8h (non-FDA approved: 400 mg PO tid for 10 d)
Recurrent oral or genital herpes: 200 mg PO 5 times/d for 5 d (non-FDA approved: 400 mg PO tid for 5 d)
Genital herpes suppression: 400 mg PO bid
Disseminated disease: 5-10 mg/kg IV q8h for 7 d if >12 years
Pediatric
Administer oral therapy as in adults
Neonatal/disseminated HSV and <12 years: 10 mg/kg IV q8h for 10 d or 250 mg/m2 q8h for 7 d
Concomitant use of probenecid or zidovudine prolongs half-life and increases CNS toxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in renal failure (adjust dose) or when taking nephrotoxic drugs; thousands of pregnancies are documented in the acyclovir registry and hundreds are in the valacyclovir and famciclovir registries without any reports of increased fetal defects or pregnancy difficulties due to these drugs
Penciclovir (Denavir)
Topical formulation. For use in mild recurrent herpes labialis. Inhibitor of DNA polymerase in HSV-1 and HSV-2 strains, inhibiting viral replication.
Adult
Apply 1% cream q2h while awake for 4-5 d
Pediatric
Apply as in adults
None reported
Documented hypersensitivity; previous adverse reaction to famciclovir
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
May experience mild erythema
Famciclovir (Famvir)
Prodrug that, when biotransformed into its active metabolite penciclovir may inhibit viral DNA synthesis/replication.
Adult
Recurrent herpes labialis: 1500 mg PO as single dose at onset of symptoms
Genital herpes, primary episode: 250 mg PO tid for 10 d
Episodic genital herpes (recurrent episodes): 1000 mg PO q12 h for 24 h at onset of symptoms (within 6 h of first sign/symptom)
Long-term suppression: 250 mg PO bid
HIV-positive individuals with recurrent genital or orolabial HSV infection: 500 mg PO bid for 7 d (adjust dose for renal insufficiency)
Recurrent genital herpes simplex suppression (HIV-infected patient): 500 mg PO bid
Pediatric
Not established
Coadministration of probenecid or cimetidine may increase toxicity; coadministration increases bioavailability of digoxin
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in renal failure or with coadministration of nephrotoxic drugs; thousands of pregnancies are documented in the acyclovir registry and hundreds are in the valacyclovir and famciclovir registries without any reports of increased fetal defects or pregnancy difficulties due to these drugs
Caution in glucose-galactose malabsorption or intolerance or severe lactase deficiency (tablets contain lactose); acute renal failure reported
Valacyclovir (Valtrex)
Prodrug rapidly converted to the active drug acyclovir. More expensive but has a more convenient dosing regimen than acyclovir.
Adult
Herpes labialis: 2000 mg PO q12h for 24 h (must be taken at first sign of symptoms/prodrome)
Genital herpes, primary episode: 1000 mg PO bid for 10 d
Recurrent genital herpes: 500 mg PO bid for 3 d
Genital herpes suppression (9 or fewer recurrences per year or HIV-positive individuals: 500 mg PO qd
Recurrent genital herpes simplex, suppression (HIV-infected patient): 500 mg PO bid
If >9 recurrences per year: 1000 mg PO qd
Pediatric
Not established
Probenecid, zidovudine, or cimetidine coadministration prolongs half-life and increases CNS toxicity; mycophenolate may increase toxicity; tenofovir disoproxil fumarate and valacyclovir may increase serum concentrations of either drug due to decreased renal clearance by competition for tubular secretion
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adverse reactions include thrombocytopenia, facial edema, rash, urticaria, and GI upset; monitor for neutropenia) caution in renal failure and with coadministration of nephrotoxic drugs; rarely associated with onset of hemolytic uremic syndrome/ thrombotic thrombocytopenic purpura if given in massive dose; thousands of pregnancies are documented in the acyclovir registry and hundreds are in the valacyclovir and famciclovir registries without any reports of increased fetal defects or pregnancy difficulties due to these drugs
Foscarnet (Foscavir)
Organic analog of inorganic pyrophosphate that inhibits replication of known herpesviruses, including CMV, HSV-1, and HSV-2. Inhibits viral replication at 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 maintenance dose of 120 mg/kg/d early in treatment. Individualize dosing based on renal function status.
Adult
Acyclovir-resistant HSV infections: 40 mg/kg IV q8-10h for 10-21 d
Mucocutaneous, acyclovir-resistant: 40 mg/kg IV, over 1 h, q8-12h for 2-3 wk or until healed
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Coadministration with potentially nephrotoxic drugs (eg, aminoglycosides, amphotericin B, IV pentamidine) may increase nephrotoxicity (do not administer unless potential benefits outweigh risks); coadministration with IV pentamidine may cause hypocalcemia
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May cause decline in renal function for correct dosing, obtain 24-h serum creatinine at baseline and continue to monitor (discontinue if serum creatinine level <0.4 mL/min/kg); hydration may reduce nephrotoxicity; carefully monitor electrolyte levels (eg, calcium, magnesium); assess for electrolyte and mineral level abnormalities if mild perioral numbness, paresthesia, or seizures; granulocytopenia and anemia may occur (regularly monitor CBC); infuse foscarnet solutions into veins with adequate blood flow to avoid local irritation; to avoid toxicity, do not administer by rapid or bolus IV injection; may deposit in teeth and bone (deposition is greater in young and growing animals); can prolong QT interval in some patients, which may result in ventricular tachycardia, ventricular fibrillation, and torsades de pointes; concurrent administration of foscarnet with tricyclic antidepressants, erythromycin, or antipsychotic agents may increase toxicity of the drug
Cidofovir (Vistide)
Approved for treatment of CMV retinitis. Compounded cream/gel (not FDA approved but recommended by CDC) can be used for localized acyclovir-resistant HSV.
Adult
1 topical application qd
Pediatric
Not established
Coadministration of aminoglycosides, amphotericin B, IV pentamidine, and foscarnet may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Rarely results in nephrotoxicity and metabolic acidosis; iritis and uveitis have been reported, especially in patients concomitantly receiving protease inhibitors; neutropenia, anemia, rash, and contact dermatitis are uncommon
Docosanol cream 10 % (Abreva)
Used for HSV-1 infections. Prevents viral entry and replication at cellular level. Use at first sign of cold sore or fever blister.
Adult
Herpes labialis: Apply topically 5 times/d for 5-10 d (until healed)
Pediatric
<12 years: Not established
>12 years: Apply as in adults
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
For external use only; not for use inside mouth or around eyes; may cause headaches
More on Herpes Simplex |
| Overview: Herpes Simplex |
| Differential Diagnoses & Workup: Herpes Simplex |
 Treatment & Medication: Herpes Simplex |
| Follow-up: Herpes Simplex |
| Multimedia: Herpes Simplex |
| References |
| Further Reading |
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Keywords
herpes simplex virus, HSV, herpes genitalis, genital herpes, herpes labialis, orolabial herpes, HSV-1, HSV type 1, herpes simplex virus type 1, HSV-2, HSV type 2, herpes simplex virus type 2, localized eczema herpeticum, disseminated eczema herpeticum, Kaposi's varicelliform eruption, Kaposi varicelliform eruption, herpes whitlow, herpes gladiatorum, disseminated HSV infection, neonatal HSV infection, herpetic sycosis
