eMedicine Specialties > Emergency Medicine > Infectious Diseases

Herpes Simplex: Treatment & Medication

Author: Rahul Sharma, MD, MBA, Instructor in Medicine, Weill Medical College of Cornell University; Consulting Staff, Department of Emergency Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center
Coauthor(s): Lawrence C Brilliant, MD, Clinical Assistant Professor, Department of Primary Care and Community Services, Hahnemann University; Attending Physician, Department of Emergency Medicine, Doylestown Hospital
Contributor Information and Disclosures

Updated: Sep 4, 2008

Treatment

Emergency Department Care

ED care consists of diagnosis and appropriate treatment. Most patients may be treated in the outpatient setting. Identification of patients that need inpatient treatment (ie, encephalitis) and initiation of antiviral and supportive therapy is imperative.

Consultations

  • Ophthalmologist for keratoconjunctivitis
  • Obstetrician for active genital herpes in a near-term pregnancy
  • Outpatient dermatologist for differentiation of skin infections
  • Infectious disease specialist for disseminated disease and encephalitis

Medication

Antiviral drugs with activity against viral DNA synthesis have been effective against HSV infections. These drugs inhibit virus replication and may suppress clinical manifestations but are not a cure for the disease. Since HSV remains latent in sensory ganglia, the rates of relapse are similar in treated and untreated patients.

Acyclovir (Zovirax) provides initial, recurrent, and suppressive therapy for genital HSV. It is effective for mucocutaneous HSV in an immunocompromised host as well as HSV encephalitis. Little evidence supports the routine use of acyclovir for primary oral-labial HSV. Oral acyclovir has been shown to be effective in suppressing herpes labialis in immunocompromised patients with frequent recurrent infections. One study reported that oral acyclovir reduced duration of pain by 36% and time to loss of crust by 27%. Begin use during the prodromal period.

Administer famciclovir (Famvir) or valacyclovir (Valtrex) for recurrent episodes of genital HSV. Herpes simplex keratoconjunctivitis is treated with topical 1% trifluridine (Viroptic).

Use pain medication as needed.  Many patients may require narcotics for the relief of severe pain from the lesions.

Antiviral agents

The goals in use of antivirals are to (1) shorten the clinical course, (2) prevent complications, (3) prevent the development of latency and/or subsequent recurrences, (4) decrease transmission, and (5) eliminate established latency.


Acyclovir (Zovirax)

DOC; reduces duration of symptomatic lesions. Indicated for patients presenting within 48 h of rash onset. Patients on acyclovir experience less pain and faster resolution of cutaneous lesions.

Adult

Genital HSV
First episode: 200 mg PO 5 times/d for 10 d or 400 mg PO tid for 7-10 d (equally effective)
Recurrent episodes: 400 mg PO tid for 5 d
Suppressive therapy: 400 mg PO bid
Mucocutaneous HSV in immunocompromised host
Mild: 200-400 mg 5 times/d for 10 d
Severe: 5 mg/kg IV q8h for 7-10 d or 400 mg PO 5 times/d for 14-21 d
Encephalitis: 10 mg/kg IV q8h for 14-21 d
Herpetic whitlow: 400 mg PO tid for 10 d
Frequently recurrent herpes labialis: 400 mg PO bid for 4 mo

Pediatric

Immunocompromised: 250-600 mg/m2/dose PO 4-5 times/d for 7-10 d
HSV encephalitis: 10 mg/kg/dose IV or 500 mg/m2/dose q8h

Probenecid or zidovudine prolongs half-life and increases CNS toxicity

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

Caution in renal failure or with coadministration of other nephrotoxic drugs; some adverse effects include nausea, vomiting, rash, deposition in renal tubules, and CNS symptoms


Famciclovir (Famvir)

Prodrug that, when biotransformed into active metabolite penciclovir, may inhibit viral DNA synthesis/replication. Useful for recurrent episodes of genital HSV.

Adult

125-250 mg PO bid/tid for 5 d

Pediatric

Not established

Probenecid or cimetidine prolongs half-life (may increase toxicity); increases bioavailability of digoxin

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 coadministration of nephrotoxic drugs


Valacyclovir (Valtrex)

Prodrug that is rapidly converted to acyclovir before exerting its antiviral activity. Valacyclovir is more expensive but has more convenient dosing regimen than acyclovir. Useful for recurrent episodes of genital HSV.

Adult

500-1000 mg PO bid for 5-10 d

Pediatric

Not established

Probenecid, zidovudine, or cimetidine prolongs half-life and increases CNS toxicity

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in renal failure and coadministration of nephrotoxic drugs; associated with onset of hemolytic uremic syndrome


1% Trifluridine (Viroptic)

Replaces thymidine in viral DNA, resulting in production of defective proteins and thus inhibiting viral replication. Useful in treatment of keratoconjunctivitis.

Adult

1 gtt q2h until corneal ulcer has re-epithelialized completely; not to exceed 9 gtt/d

Pediatric

Not established

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 mild local transient irritation of conjunctivae and cornea upon instillation


Docosanol cream (Abreva)

Prevents viral entry and replication at cellular level. Use at first sign of cold sore or fever blister.

Adult

Apply 5 times/d to affected area on lips or face and continue application until healed

Pediatric

<12 years: Not established
>12 years: Apply as in adults

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 to be used for inside of mouth or near 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
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References

  1. Benedetti J, Corey L, Ashley R. Recurrence rates in genital herpes after symptomatic first-episode infection. Ann Intern Med. Dec 1 1994;121(11):847-54. [Medline].

  2. Clark JL, Tatum NO, Noble SL. Management of genital herpes. Am Fam Physician. Jan 1995;51(1):175-82, 187-8. [Medline].

  3. Cockerell C. Diagnosis and treatment of cutaneous herpes simplex virus infections. West J Med. Jun 1996;164(6):518-20. [Medline].

  4. Frenkl TL, Potts J. Sexually transmitted infections. Urol Clin North Am. Feb 2008;35(1):33-46; vi. [Medline].

  5. Hill J, Roberts S. Herpes simplex virus in pregnancy: new concepts in prevention and management. Clin Perinatol. Sep 2005;32(3):657-70. [Medline].

  6. Hirsch MS. Herpes simplex virus. In: Mandell GL, ed. Mandell, Douglas, and Bennet's Principles and Practice of Infectious Diseases. 4th ed. Churchill Livingstone; 1995:1336-45.

  7. Holland-Hall C. Sexually transmitted infections: screening, syndromes, and symptoms. Prim Care. Jun 2006;33(2):433-54. [Medline].

  8. Johnson R. Herpes gladiatorum and other skin diseases. Clin Sports Med. Jul 2004;23(3):473-84, x. [Medline].

  9. Patel R, Rompalo A. Managing patients with genital herpes and their sexual partners. Infect Dis Clin North Am. Jun 2005;19(2):427-38, x. [Medline].

  10. Rooney JF, Straus SE, Mannix ML. Oral acyclovir to suppress frequently recurrent herpes labialis. A double-blind, placebo-controlled trial. Ann Intern Med. Feb 15 1993;118(4):268-72. [Medline].

  11. Whitley RJ, Gnann JW Jr. Acyclovir: a decade later. N Engl J Med. Sep 10 1992;327(11):782-9. [Medline].

  12. Wu JJ, Pang KR, Huang DB. Advances in antiviral therapy. Dermatol Clin. Apr 2005;23(2):313-22. [Medline].

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Further Reading

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Contributor Information and Disclosures

Author

Rahul Sharma, MD, MBA, Instructor in Medicine, Weill Medical College of Cornell University; Consulting Staff, Department of Emergency Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center
Rahul Sharma, MD, MBA is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

Lawrence C Brilliant, MD, Clinical Assistant Professor, Department of Primary Care and Community Services, Hahnemann University; Attending Physician, Department of Emergency Medicine, Doylestown Hospital
Lawrence C Brilliant, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

Robin R Hemphill, MD, MPH, Associate Professor, Director, Disaster Preparedness, Department of Emergency Medicine, Vanderbilt University Medical Center
Robin R Hemphill, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Eric L Weiss, MD, DTM&H, Director of Stanford Travel Medicine, Medical Director of Stanford Lifeflight, Assistant Professor, Departments of Emergency Medicine and Infectious Diseases, Stanford University School of Medicine
Eric L Weiss, MD, DTM&H is a member of the following medical societies: American College of Emergency Physicians, American College of Occupational and Environmental Medicine, American Medical Association, American Society of Tropical Medicine and Hygiene, Physicians for Social Responsibility, Southeastern Surgical Congress, Southern Association for Oncology, Southern Clinical Neurological Society, and Wilderness Medical Society
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Steven C Dronen, MD, FAAEM, Director of Emergency Services, Director of Chest Pain Center, Department of Emergency Medicine, Ft Sanders Sevier Medical Center
Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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