eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Herpes Simplex Virus Infection: Treatment & Medication

Author: Sherman Alter, MD, Associate Professor, Department of Pediatrics, Wright State University Boonshoft School of Medicine; Director, Division of Infectious Diseases, Director, Continuing Medical Education, Children's Medical Center of Dayton
Contributor Information and Disclosures

Updated: Aug 6, 2009

Treatment

Medical Care

  • Specific medical therapy of herpes simplex virus (HSV) infections involves antiviral medications. The approach to therapy also may involve antipyretics for fever control and medications to alleviate associated pain.
  • Appropriate care for wounds is indicated, and therapy for bacterial infections is warranted in cases of secondary infection.
  • Aggressive inpatient and/or intensive medical care are needed in the management of neonatal herpes simplex virus infections, herpes simplex virus encephalitis, and herpetic infections in immunocompromised hosts.
  • In Mollaret meningitis, therapy is primarily symptomatic because symptoms and signs resolve over days. Prophylactic administration of acyclovir may prevent repeated attacks.
  • Therapy of erythema multiforme (EM) generally addresses the dermatologic manifestations and not the viral infection. Suppression of recurrences with acyclovir prophylaxis may prevent recurrent EM in some patients.

Consultations

  • Consultation with physicians experienced in caring for seriously ill patients with infectious diseases is recommended for neonatal herpes simplex virus infections, herpes simplex virus encephalitis or disseminated disease, and herpes simplex virus infection in patients who are immunocompromised. Such physicians may include neonatologists, critical care specialists, and infectious disease physicians.
  • A consultation with an ophthalmologist is imperative in the management of herpes simplex virus eye infections.
  • For a child with genital herpes simplex virus infection that is suspected to be a result of child abuse (see Media file 3), consultation with social services and/or a physician experienced in managing child and/or sexual abuse is warranted.

    Cutaneous herpes simplex virus (HSV) lesions in a...

    Cutaneous herpes simplex virus (HSV) lesions in a child in whom sexual abuse is suspected.

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    Cutaneous herpes simplex virus (HSV) lesions in a...

    Cutaneous herpes simplex virus (HSV) lesions in a child in whom sexual abuse is suspected.

Medication

Antiviral agents used to treat herpes simplex virus (HSV) infections are nucleoside analogs. Acyclovir is the antiviral most commonly used to treat herpes simplex virus infections. Other oral medications include famciclovir, which is a prodrug that is converted to penciclovir, and valacyclovir, which is a prodrug that is converted to acyclovir. Oral therapy is effective for non–life-threatening herpes simplex virus infections (eg, primary orolabial, genital). Intravenous (IV) acyclovir is indicated for the treatment of encephalitis, any form of neonatal disease, severe infection in patients who are immunocompromised, and occasional cases of severe orolabial or genital disease. It is also useful in the suppression of recurrent genital herpes simplex virus infections to diminish viral shedding and decrease rates of clinical recurrences.

A recent study examined the use of antiviral agents in neonates with herpes simplex virus.7 The study determined that the trial evidence is insufficient to evaluate the effects of antiviral agents in this population. The study also concluded that the efficacy of newer agents with better bioavailabilty and of oral formulations need further evaluation.

Antiviral agents

Acyclovir, a synthetic acyclic purine nucleoside analog, is the standard treatment for herpes simplex virus type 1 (HSV-1) and herpes simplex virus type 2 (HSV-2) infections. Activation of the drug requires 3 phosphorylations. Herpes simplex virus thymidine kinase adds the first phosphate. Acyclovir binds 200-300 times more avidly to viral thymidine kinase than to host enzyme. After final cellular phosphorylation, the nucleoside triphosphate effectively inhibits DNA polymerase and acts as a DNA chain terminator. Precursors of acyclovir (ie, valacyclovir, famciclovir) have bioavailability better than that of their active metabolites (acyclovir and penciclovir, respectively).


Acyclovir (Zovirax)

Inhibits activity of HSV-1 and HSV-2. Patients experience least pain and fastest resolution of cutaneous lesions with prompt start of therapy, usually within 48 h after rash onset. Selectively incorporated into infected cells. May prevent recurrent outbreaks. Long record of use with excellent safety profile.
Available as oral susp 200 mg/5 mL, tab, cap, injection, and topical formulation. Topical form does not appear to be effective in recurrent mucocutaneous or genital HSV infections and offers no advantage over oral form in treating primary genital HSV infections. For obese patients, calculate IV dose according to ideal body weight.

Adult

First episode of mucocutaneous HSV infection:
200 mg PO 5 times/d or 400 mg PO tid for 7-10 d or until clinical resolution occurs
Recurrent genital HSV infection: 800 mg PO 3 times/d for 2 d or 400 mg PO tid for 3-5 d
Chronic suppression: 400 mg PO bid (titrate dose as required); reevaluate after 1 y
Mucocutaneous HSV infection in immunocompromised patient: 5-10 mg/kg IV q8h for 7-14 d
Minor lesions: 200-400 mg PO 5 times/d for 10-14 d
HSV encephalitis: 10-15 mg/kg IV q8h for 14-21 d

Pediatric

HSV gingivostomatitis: 15 mg/kg PO 5 times/d for 7 d; or 600 mg/m2/dose PO 4 times/d for 10 d.
Severe disease: 5 mg/kg IV or 250 mg/m2 IV q8h for 5-7 d
First episode genital HSV infection: 200 mg PO 5 times/d for 7-10 d or 400 mg PO tid for 7-10 d
Severe disease: 5 mg/kg IV or 250 mg/m2 IV q8h for 5-7 d
Neonatal HSV infection (SEM, encephalitis, disseminated):
Preterm infant: 10 mg/kg IV q8h (extend dose interval to q12h in premature infant <34 wk)
Term infant: 20 mg/kg IV q8h for 14-21 d (21 d for encephalitis or disseminated)
HSV encephalitis: 10-15 mg/kg IV q8h for 14-21 d
Mucocutaneous HSV in immunocompromised states: 30 mg/kg/d IV divided q8h for 14-21 d

Concomitant use of zidovudine or probenecid prolongs half-life and can increase 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 (adjust dose); renal dysfunction (usually reversible) can occur during high-dose IV administration (primarily related to drug crystalluria); can minimize effect by using slow infusion rate; neurologic symptoms include lethargy, myoclonus, or seizures (<1%); appears to be dose-related phenomenon, with increased risk with azotemia


Valacyclovir (Valtrex)

Prodrug rapidly converted to active drug acyclovir. More expensive but more convenient dosing regimen and superior bioavailability than that of oral acyclovir. Use in adolescent HSV infection.

Adult

First episode oral mucocutaneous HSV infection: 2000 mg PO bid for 1 d
First episode genital mucocutaneous HSV infection: 1000 mg PO bid for 10 d
Recurrent genital HSV infection: 500 mg PO bid for 3 d
Chronic suppression: 1000 mg PO qd; in patients with <9 recurrences annually, may use 500 mg PO qd; increase to 1000 mg PO qd if breakthrough at lower dose occurs

Pediatric

Not established
Adolescents: Administer as in adults

Probenecid, zidovudine, or cimetidine coadministration 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 (adjust dose) and with coadministration of nephrotoxic drugs; associated with onset of hemolytic uremic syndrome


Famciclovir (Famvir)

Transformed in vivo to active nucleoside analogue penciclovir, which can effectively inhibit HSV DNA synthesis and/or replication. More expensive but more convenient dosing regimen than that of acyclovir. Use in adolescent HSV infection.

Adult

First episode mucocutaneous HSV infection: 250 mg PO tid for 7-10 d
Recurrent genital infection: 1000 mg PO bid for 1 d
Chronic suppression: 250 mg PO bid

Pediatric

Not established
Adolescents: Administer as in adults

Coadministration of probenecid or cimetidine 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 (adjust dose) and with coadministration of nephrotoxic drugs


Penciclovir (Denavir)

1% cream approved for treatment of recurrent orolabial HSV infection. Nucleotide derivative active in vitro against HSV-1 and HSV-2. Guanosine analog that inhibits viral DNA synthesis. Negligible systemic absorption after topical use. Repeated application of cream beginning shortly after onset of recurrent HSV symptoms and continued for 4 d shortens healing time to about 1 d. May also shorten duration of viral shedding. Not approved by the FDA for use in children.

Adult

Apply and cover lesion immediately at first prodromal symptoms and q2h (during awake hours) for 4 d

Pediatric

Not FDA approved for children; limited data; administer as in adults

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

Mild erythema possible; do not apply to mucosal surfaces

More on Herpes Simplex Virus Infection

Overview: Herpes Simplex Virus Infection
Differential Diagnoses & Workup: Herpes Simplex Virus Infection
Treatment & Medication: Herpes Simplex Virus Infection
Follow-up: Herpes Simplex Virus Infection
Multimedia: Herpes Simplex Virus Infection
References
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Further Reading

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Keywords

HSV, herpes, Herpesvirus hominis, human herpesvirus, herpesvirus type 1, herpesvirus type 2, HSV-1, HSV-2, herpes catarrhalis, herpes facialis, herpes febrilis, herpes labialis, orolabial herpetic infection, Simplex virus, Simplexvirus, neonatal HSV infection, SEM HSV disease, herpetic whitlow, herpes gladiatorum, meningitis, encephalitis, erythema multiform, EM, acuteherpetic pharyngotonsillitis, acute herpetic gingivostomatitis, genital herpes, Mollaret meningitis, keratoconjunctivitis, sexually transmitted disease, STD, genital HSV infections, neonatal HSV infection, orofacial infections, HSV encephalitis, disseminated HSV, odynophagia, orolabial vesicles, painful inguinal lymphadenopathy, aseptic meningitis syndrome, recurrent genital HSV, recurrent genital infections, transverse myelitis, HSV pneumonitis, HSV esophagitis, acute retinal necrosis, erythema multiforme, HSV keratoconjunctivitis, microphthalmos, retinal dysplasia, quadriplegia, microcephaly, recurrent HSV vesicular lesions, orolabial HSV infections, HSV pharyngotonsillitis, recurrent orolabial herpetic infection, HSV CNS disease, HSV-induced aseptic meningitis, HSV hepatitis, blepharitis, follicular conjunctivitis, uveitis, retinitis, punctate retinal lesions, congenital HSV infection

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Contributor Information and Disclosures

Author

Sherman Alter, MD, Associate Professor, Department of Pediatrics, Wright State University Boonshoft School of Medicine; Director, Division of Infectious Diseases, Director, Continuing Medical Education, Children's Medical Center of Dayton
Sherman Alter, MD is a member of the following medical societies: American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Society for Healthcare Epidemiology of America
Disclosure: Glaxosmithkline Grant/research funds Other; Merck Honoraria Speaking and teaching; Novartis Grant/research funds Speaking and teaching; SanofiPasteur Honoraria None

Medical Editor

Leonard R Krilov, MD, Chief of Pediatric Infectious Diseases, Vice Chair, Department of Pediatrics, Professor of Pediatrics, Winthrop University Hospital
Leonard R Krilov, MD is a member of the following medical societies: American Academy of Pediatrics, American Pediatric Society, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Society for Pediatric Research
Disclosure: Medimmune Grant/research funds Cliinical trials; Medimmune Honoraria Speaking and teaching; Medimmune Consulting fee Consulting

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Mark R Schleiss, MD, American Legion Chair of Pediatrics, Professor of Pediatrics, Division Director, Division of Infectious Diseases and Immunology, Department of Pediatrics, University of Minnesota Medical School
Mark R Schleiss, MD is a member of the following medical societies: American Pediatric Society, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Society for Pediatric Research
Disclosure: Nothing to disclose.

CME Editor

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; sanofi pasteur Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD, Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association
Disclosure: None None None

 
 
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