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Chapter 140: Herpes Simplex Virus

Austinn C. Miller; Susuana Adjei; Stephen K. Tyring

HERPES SIMPLEX VIRUS

Therapeutic Approach

Herpes simplex virus (HSV) is a common, human DNA viral pathogen. There are 2 types: HSV-1 and HSV-2, which primarily present as orofacial and genital infections. However, both types can occur anywhere on the body. Clinical manifestations vary depending on the site of infection, immune status of the host, and whether infection is primary or recurrent. Many HSV infections only require supportive care. Therapy should be based on symptoms and the site affected. In the authors’ experience, oral valacyclovir is first-line therapy for most localized infections, with IV acyclovir reserved for severe disseminated infections. Topical therapy is rarely initiated given its multiple daily applications and decreased efficacy when compared to systemic therapy. See Table 140-1.

Table 140-1Herpes Simplex Virus Treatment Table
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Table 140-1 Herpes Simplex Virus Treatment Table
MEDICATION NAME INDICATIONb MECHANISM OF ACTION DOSING ADVERSE EFFECTS SUGGESTED MONITORING LEVEL OF EVIDENCE (REFERENCE)
Topical Therapy
Penciclovir OFRI(e) Antiviral 1% cream; apply q2h while awake Skin irritation (<2%) None IA1
Docosanol OFRI(e) Antiviral 10% cream, apply 5 times per day Skin irritation (<3%) None IB2,3
Acyclovir OFRI(e)* Antiviral 5% cream; apply 5 times per day,a 50 mg buccal tablet Skin irritation (<30%) None IA4
Systemic Therapy
Acyclovir OFPI Antiviral 200 mg PO 5 times daily for 7-10 d; 400 mg PO TID for 7-10 d Malaise (12%); GI upset (<7%); increased BUN/Cr (5%-10%) increased liver enzymes (<4%); decreased hemoglobin (13%) and neutropenia (3%-16%) in neonates; neurotoxicity (<1%), acute kidney injury (<1%), TTP (<1%)

Short term usage typically requires no monitoring.

With prolonged use, IV therapy, and RD, monitor: Hydration status, UA, urine output, CMP, CBC, signs and symptoms of neurotoxicity at baseline. For IV therapy monitor daily, for oral therapy monitor q3mo (severe RD) or q6mo (moderate RD)

In neonates receiving >60 mg/kg/d IV, monitor neutrophil count twice weekly

 IB5,6
  OFRI(e)a Antiviral 400 mg PO 5 times daily for 5 da IB7
  OFRI(s) Antiviral 400 mg PO BID, reassess periodically IB8
  GHPIa Antiviral 200 mg PO 5 times dailya for 7-10 d; 400 mg PO TID for 7-10 d IB9
  GHRI(e)* Antiviral 200 mg PO 5 times dailya for 5 d; 400 mg PO TID for 5 d; 800 mg BID for 5 d IB10
  GHRI(s)* Antiviral 400 mg PO BIDa; 800 mg PO QD; for each dosage, reassess periodically   IA11
  NH Antiviral 20 mg/kg IV q8h for 14-21 d   IIB12,13
  DI Antiviral 10-20 mg/kg IV q8h for at least 10 d   IV14
  HG Antiviral 200 mg PO 5 times daily for 7-10 d; 400 mg PO TID; for 7-10 d     IV15
  EH Antiviral 200 mg PO 5 ...

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