Herpes symptoms may let some people feel significantly uncomfortable. But treatments are available that can reduce the severity, frequency, and duration of outbreaks. Antiviral medications can prevent the virus from multiplying on the skin surface, and they can also reduce the length of time that the virus is on the skin during a herpes outbreak effectively.
Three herpes antiviral medications are currently available in tablet form – famciclovir, aciclovir and valaciclovir.
Genital Herpes Treatment
The potential benefits of antiviral therapy should be discussed with all patients. As many patients are unaware of the treatment options available to them, the responsibility lies with the clinician to provide patients with sufficient information to enable them to participate fully in management decisions. Once the patient is fully informed about the options available, the patient and clinician together can then agree upon a management strategy.
There are two basic approaches to antiviral management of the patient with recurrent genital herpes. One is ‘episodic’ oral antiviral therapy, where the patient self-administers antiviral therapy as soon as they experience a recurrence. The other is ‘suppressive’ (preventative) antiviral therapy, or ‘chemosuppression’, where the patient takes antiviral therapy continuously to prevent recurrences. While episodic therapy may only decrease the duration of lesions by one to one and a half days, some patients may find this effect clinically significant. There is also some evidence that recurrences can be aborted if antiviral therapy is begun during the prodrome. Suppressive therapy generally reduces the number of recurrences, and virus shedding, by 85-90%.
The decision whether to receive episodic antiviral therapy, suppressive antiviral therapy or no therapy at all should be made by the patient in consultation with the health care provider. The health care provider’s main role is to educate and counsel so that the patient is able to make an informed choice.
Return control of the infection to the patient
Patients managed by episodic antiviral therapy can start therapy themselves each time they detect the first signs of a recurrence. Self-initiation allows each recurrence to be treated more expeditiously than if a physician has to be consulted. Education directed at the recognition of early signs and symptoms, including prodromal symptoms, is very important. Allowing patients to self-initiate treatment without having to go back to the physician also returns control of the infection to the patient.
Antiviral Therapies
There are three drugs currently available for the treatment of herpes simplex virus, aciclovir, famciclovir and valaciclovir. All three drugs prevent replication of herpes simplex virus by inhibiting the synthesis of viral DNA. They are active only in herpes-virus-infected cells, making them extremely safe and well tolerated. Aciclovir’s only drawback is poor bioavailability, i.e. only a proportion (about one fifth) of each dose is absorbed. Famciclovir is the oral pro-drug of penciclovir, which has a similar, but not identical, mechanism of action to aciclovir. Famciclovir is well absorbed orally, making twice-daily oral therapy possible. Because valaciclovir is metabolized to aciclovir in vivo, it has exactly the same mechanism of action as aciclovir. Valaciclovir has the advantage over aciclovir in that it is virtually 100 percent absorbed by the mouth, hence making lower doses and/or less frequent dosing possible.
The table below provides a comprehensive list of the available therapies with the dose required to treat initial and recurrent episodes of genital herpes as well as for suppressive therapy. In some instances, it may be appropriate to vary doses and duration of therapy from those given here. For these cases, we recommend that advice is sought from a specialist.
Treatment of Genital Herpes Simplex Infections
| Diagnosis | Management Strategy | Drug | Dose | ||||||||||||||||
| Initial Infection | Treatment |
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| Recurrent episodes |
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| Recurrent episodes in immune compromised patients |
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TGA approved indications are included in the above table. All drugs are given orally.
- 1. Begin therapy as soon as possible; antivirals are probably ineffective after lesions have been present for >3 days. Therapy should generally be given at least until lesions have crusted.
- 2. There are no clinical trials supporting famciclovir for treating initial episodes of herpes.
- 3. Begin therapy as early as possible, preferably in the prodromal period; therapy probably not beneficial after lesions have been present for >24 hrs.
- 4. At the same daily dose of aciclovir, a thrice daily administration is slightly more effective than twice daily; more frequent administration may be needed to adequately suppress recurrences in some patients, up to 200mg 4-5 times daily.
- 5. Twice daily therapy tends to be more effective than once daily, at any given daily dose.
- 6. Minimal good clinical evidence for this indication.
Oral Herpes Treatment
People are interested in looking for effective remedies for cold sores due to the fact that
cold sores make people feel uncomfortable and unsightly. At present, there is no way of eradicating the latent infection and treatments are directed solely at the control of each outbreak. There are numerous anecdotal remedies including solvents like ether and alcohol, disinfectants like povidone iodine and miscellaneous applications such as ice and toothpaste. None of these are proven to shorten the duration of the outbreak.
Currently, there are only two topical preparations which have been shown in controlled clinical trials to influence the eruption or duration of cold sores, if applied early enough. These are aciclovir and penciclovir-containing creams called Zovirax and Vectavir, respectively. The greatest benefit is likely to be achieved if the creams are applied during the prodromal (i.e. tingling) stage of the sore. The response varies between episodes and between individuals. For further prescribing details, see product information.
Gingivostomatitis
Primary infection (gingivostomatitis) responds well to oral aciclovir. For infants and children, aciclovir tablets are easily dispersed in water or crushed tablets may be mixed with jam.
