Herpes Simplex Virus Infections

Clinical Presentation

• A tingling, burning, or itching sensation at the site of infection may occur 1-2 days before visible lesions appear in immunocompetent hosts 1
• Lesions typically last 7-10 days in immunocompetent hosts 2
• Multiple painful vesicles on genital mucosa or skin are characteristic of genital HSV, typically HSV-2, but can be HSV-1 1
• Urogenital complications, including urinary retention and dysuria, can occur 3
• Possible extensive, deep, nonhealing ulcerations can occur in patients with compromised immune systems, such as those with CD4+ counts <100 cells/μL 1
• Symptoms can be triggered by stress, sunlight, or physiologic factors 1
• HSV keratitis typically presents with unilateral involvement, bulbar conjunctival injection, watery discharge, mild follicular reaction of conjunctiva, and possible palpable preauricular lymph node, although it can be bilateral in atopic or immunocompromised patients 4
• The condition can lead to keratitis, corneal scarring, and vision impairment if left untreated, emphasizing the importance of prompt and appropriate treatment, as stated by the American Academy of Ophthalmology 5

Diagnosis and Monitoring

• Initial follow-up should be within 1 week of treatment initiation to assess symptom improvement, check for corneal involvement, and evaluate for uveitis, with scheduled follow-ups including interval history, visual acuity measurement, and slit-lamp biomicroscopy, as suggested by the American Academy of Ophthalmology 4, 5
• Patients should be monitored for dry eye and corneal anesthesia with neurotrophic keratitis, as advised by the American Academy of Ophthalmology 4

Treatment

• The Centers for Disease Control and Prevention recommends Acyclovir: 800 mg orally five times daily for 7 days, while the American Academy of Pediatrics suggests a combination of local and systemic antiviral medications for 7-14 days in children, with options including Acyclovir (200-400 mg five times daily), Valacyclovir (500 mg two or three times daily), and Famciclovir (250 mg twice daily) 6, 5
• Topical antivirals alone have not shown significant benefit but may be used as adjunctive therapy in unresponsive cases, while for uveitis, topical corticosteroids at minimum effective dose with careful monitoring must be used in conjunction with systemic antiviral therapy, as recommended by the American Academy of Ophthalmology 4
• Topical antibiotics may be used to prevent secondary infection of eyelid vesicles, according to the American Academy of Ophthalmology 4
• Severe cases or immunocompromised patients may require more aggressive treatment, including IV acyclovir, as recommended by the Centers for Disease Control and Prevention, with re-evaluation and possible therapy adjustment within 48-72 hours if there are signs of progression or lack of improvement, rated as moderate evidence by the Infectious Diseases Society of America 6, 7
• Lower doses of oral antivirals can prevent recurrent HSV keratitis in patients with frequent recurrences, while higher doses may be effective in resistant cases, requiring more aggressive treatment and longer duration 5
• If HSV stromal keratitis develops, topical steroids may be beneficial in conjunction with oral antiviral therapy, but avoid topical corticosteroids in epithelial HSV infections as they can potentiate the infection 5, 4

Prevention

• The American Academy of Ophthalmology recommends educating parents and children on hygiene rules, including frequent handwashing and avoiding close contact with others, to prevent infection spread 4
• Topical and oral antiviral medications can prevent progression of HSV blepharoconjunctivitis, with topical ganciclovir 0.15% gel and oral antiviral therapy being the most effective approach, and Ganciclovir 0.15% gel preferred due to less ocular surface toxicity 5

Special Considerations

• Neonatal cases require prompt consultation with a pediatrician as systemic HSV infection is life-threatening 5
• Involvement of an experienced ophthalmologist is strongly recommended for all cases of herpes zoster ophthalmicus 6
• Higher risk of acyclovir-resistant infections is associated with certain patient populations, such as those with compromised immune systems 1