Treatment of Herpes Simplex Virus Infection

Introduction to Treatment

The Centers for Disease Control and Prevention recommends Acyclovir as the treatment of choice for herpes simplex virus infections, with dosing regimens varying based on clinical presentation, severity, and patient factors 1, 2

For first episodes of genital herpes, the American College of Obstetricians and Gynecologists recommends Acyclovir 400 mg orally three times daily for 7-10 days 2
For first episodes of genital herpes, the Centers for Disease Control and Prevention recommends Acyclovir 200 mg orally five times daily for 7-10 days 3, 2
For herpes proctitis, the Centers for Disease Control and Prevention recommends higher dosages of Acyclovir, such as 400 mg orally five times daily for 10 days or until clinical resolution 3, 2

For recurrent genital herpes episodes, the American College of Obstetricians and Gynecologists recommends shorter courses of Acyclovir, such as 400 mg orally three times daily for 5 days 2
Treatment should be initiated at the first sign of prodrome or within 1-2 days of lesion onset for maximum effectiveness, as recommended by the Centers for Disease Control and Prevention 3, 2

For patients with frequent recurrences (≥6 per year), the Centers for Disease Control and Prevention recommends suppressive therapy with Acyclovir 400 mg orally twice daily 3, 2
Suppressive therapy reduces frequency of recurrences by ≥75% and reduces asymptomatic viral shedding, according to the American College of Obstetricians and Gynecologists 2

For herpes simplex encephalitis, immediate treatment is critical to reduce mortality, and the Infectious Diseases Society of America recommends Acyclovir 10 mg/kg intravenously every 8 hours for 14-21 days in adults and children with normal renal function 1, 4, 5
Early treatment (within 4 days of symptom onset) reduces mortality from 28% to 8%, as reported by the Infectious Diseases Society of America 1, 5

Immunocompromised patients may require longer courses of therapy and closer monitoring, according to the Infectious Diseases Society of America 7, 2

For neonatal herpes infections, the American Academy of Pediatrics recommends Acyclovir 20 mg/kg intravenously every 8 hours for 21 days 1, 6
Higher-dose regimen has decreased mortality to 5%, as reported by the American Academy of Pediatrics 1, 6

Topical acyclovir is substantially less effective than oral therapy and is not recommended by the Centers for Disease Control and Prevention 3, 2
Antiviral medications do not eradicate latent virus or affect the risk of recurrences after treatment is discontinued, according to the Centers for Disease Control and Prevention 3, 2
Relapse of herpes simplex encephalitis can occur after completion of therapy (rates up to 5%), particularly with shorter treatment courses, as reported by the Infectious Diseases Society of America 1, 6
For severe HSV disease during immunomodulator therapy, antiviral therapy should be initiated and immunomodulators discontinued until symptoms improve, according to the Journal of Crohn's and Colitis 7

Delayed initiation of therapy for herpes simplex encephalitis (>4 days after symptom onset) is associated with significantly higher mortality and should be avoided, as recommended by the Infectious Diseases Society of America 1, 5