Medication Summary

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.

Class Summary

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 topical

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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 (Denavir)

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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 (Famvir)

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Famciclovir is a prodrug that when biotransformed into its active metabolite, penciclovir, may inhibit viral DNA synthesis/replication.

Valacyclovir (Valtrex)

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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 (Foscavir)

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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 (Vistide)

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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% (Abreva)

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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.

Questions

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Media Gallery

Characteristic cluster of vesicles on an erythematous base. Photo courtesy of Dr. John Reeves.

of 1

Author

Sean P McGregor, DO, PharmD Resident Physician, Department of Dermatology, Baptist Health Medical Center, Wake Forest University School of Medicine

Sean P McGregor, DO, PharmD is a member of the following medical societies: American Academy of Dermatology, American Osteopathic College of Dermatology, American Society for Dermatologic Surgery, American Society for Laser Medicine and Surgery, American Society of Health-System Pharmacists, Sigma Sigma Phi

Disclosure: Nothing to disclose.

Coauthor(s)

William W Huang, MD, MPH, FAAD Associate Professor and Residency Program Director, Department of Dermatology, Wake Forest Baptist Health, Wake Forest University School of Medicine

William W Huang, MD, MPH, FAAD is a member of the following medical societies: American Academy of Dermatology, Association of Professors of Dermatology, Dermatology Foundation, Medical Dermatology Society, North Carolina Medical Society, Women's Dermatologic Society

Disclosure: Research PI for Sponsored Trial for: Gilead; Genentech;.

Specialty Editor Board

Michael J Wells, MD, FAAD Dermatologic/Mohs Surgeon, The Surgery Center at Plano Dermatology

Michael J Wells, MD, FAAD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Texas Medical Association

Disclosure: Nothing to disclose.

Rosalie Elenitsas, MD Herman Beerman Professor of Dermatology, University of Pennsylvania School of Medicine; Director, Penn Cutaneous Pathology Services, Department of Dermatology, University of Pennsylvania Health System

Rosalie Elenitsas, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, American Society of Dermatopathology, Pennsylvania Academy of Dermatology

Disclosure: Received royalty from Lippincott Williams Wilkins for textbook editor.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Received income in an amount equal to or greater than $250 from: Elsevier; WebMD<br/>Served as a speaker for various universities, dermatology societies, and dermatology departments.

Additional Contributors

Joseph S Eastern, MD Clinical Assistant Professor, Department of Internal Medicine, Section of Dermatology, University of Medicine and Dentistry of New Jersey; Clinical Assistant Professor, Seton Hall University School of Graduate Medical Education

Joseph S Eastern, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, International Society for Dermatologic Surgery, Medical Society of New Jersey

Disclosure: Nothing to disclose.

Sungnack Lee, MD Vice President of Medical Affairs, Professor, Department of Dermatology, Ajou University School of Medicine, Korea

Sungnack Lee, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors, Malcolm Schinstine, MD, PhD; Paul Krusinski, MD; Gisela Torres, MD; and Stephen K Tyring, MD, PhD, MBA, to the development and writing of this article.