Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

CNS involvement: encephalitis or meningitis

1st line – intravenous aciclovir

Back
ACUTE
|
CNS involvement: encephalitis or meningitis
1st line – 

intravenous aciclovir

Suspected or confirmed CNS disease should be treated with high-dose intravenous aciclovir. In most cases, therapy should be continued for at least 21 days. See Encephalitis.

Patients should be managed with the assistance of an infectious disease consultant.

Primary options

aciclovir: 10 mg/kg intravenously every 8 hours for 14-21 days

disseminated visceral involvement: oesophagitis, pneumonitis, or hepatitis

1st line – intravenous aciclovir

Back
ACUTE
|
disseminated visceral involvement: oesophagitis, pneumonitis, or hepatitis
1st line – 

intravenous aciclovir

Suspected or confirmed disseminated HSV infection, including oesophagitis, hepatitis, pneumonitis should be treated with high-dose intravenous aciclovir. Length of therapy depends on severity and site of disease: in most cases, therapy should be continued for at least 21 days.

Patients should be managed with the assistance of an infectious disease consultant.

Primary options

aciclovir: 5-10 mg/kg intravenously every 8 hours for 10-21 days

genital disease: first episode, immunocompetent, non-pregnant

1st line – oral antiviral therapy

Back
ACUTE
|
genital disease: first episode, immunocompetent, non-pregnant
1st line – 

oral antiviral therapy

Therapy for the first episode is the most critical and should be provided for all patients. Treatment reduces the risk of neurological complications, limits the severity and duration of the disease, and provides symptomatic relief.[60] Valaciclovir, famciclovir, and aciclovir are approved for active disease.[37]

Therapy should be started within 48-72 hours of onset of signs or symptoms. Dosages and duration of therapy differ depending on the drug and the immune status of the host. Duration of therapy should be extended until all lesions are resolved, particularly in the immunocompromised population. Resistance to these drugs is very rare.[62]

Treatment of genital herpes with topical antiviral drugs offers minimal clinical benefit, and use is discouraged.[37]​​[52]​​​ An additional concern is that topical creams may delay the healing of genital herpes recurrences.

Primary options

aciclovir: 400 mg orally three times daily for 7-10 days

OR

valaciclovir: 1000 mg orally twice daily for 7-10 days

OR

famciclovir: 250 mg orally three times daily for 7-10 days

Consider – symptomatic treatment

Back
ACUTE
|
genital disease: first episode, immunocompetent, non-pregnant
Consider – 

symptomatic treatment

Additional treatment recommended for SOME patients in selected patient group

Prompt initiation of oral antiviral therapy provides the most effective and safe symptomatic treatment available.

Analgesics and sitz baths, in which the affected genital area is immersed in warm water, can decrease pain associated with severe or prolonged recurrences.[9] External dysuria may also be alleviated by urinating with the genitals submerged in water.

If additional symptom relief is required, topical lidocaine may be used to manage pain, especially that associated with first-episode genital herpes. Patients should be made aware that lidocaine is associated with allergic reactions.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: 400-600 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

lidocaine topical: (5% ointment) apply to the affected area(s) two to three times daily when required

genital disease: first episode, immunocompromised, non-pregnant

1st line – oral antiviral therapy

Back
ACUTE
|
genital disease: first episode, immunocompromised, non-pregnant
1st line – 

oral antiviral therapy

Therapy for the first episode is the most critical and should be provided for all patients. Treatment reduces the risk of neurological complications, limits the severity and duration of the disease, and provides symptomatic relief.[60] Valaciclovir, famciclovir, and aciclovir are approved for active disease.[37]

Therapy provides greatest benefit when started within 48-72 hours of onset of signs or symptoms. Dosages and duration of therapy differ depending on the drug and the immune status of the host. Duration of therapy should be extended until all lesions are resolved, particularly in the immunocompromised population. Resistance to these drugs is very rare.[62]

Treatment of genital herpes with topical antiviral drugs offers minimal clinical benefit, and use is discouraged.[37]​​[52]​​​ An additional concern is that topical creams may delay the healing of genital herpes recurrences.

Primary options

aciclovir: 400 mg orally three times daily for 5-10 days

OR

valaciclovir: 1000 mg orally twice daily for 5-10 days

OR

famciclovir: 500 mg orally twice daily for 5-10 days

Consider – symptomatic treatment

Back
ACUTE
|
genital disease: first episode, immunocompromised, non-pregnant
Consider – 

symptomatic treatment

Additional treatment recommended for SOME patients in selected patient group

Prompt initiation of oral antiviral therapy provides the most effective and safe symptomatic treatment available.

Analgesics and sitz baths, in which the affected genital area is immersed in warm water, can decrease pain associated with severe or prolonged recurrences.[9] External dysuria may also be alleviated by urinating with the genitals submerged in water.

If additional symptom relief is required, topical lidocaine may be used to manage pain, especially that associated with first-episode genital herpes. Patients should be made aware that lidocaine is associated with allergic reactions.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: 400-600 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

lidocaine topical: (5% ointment) apply to the affected area(s) two to three times daily when required

2nd line – foscarnet

Back
ACUTE
|
genital disease: first episode, immunocompromised, non-pregnant
2nd line – 

foscarnet

Foscarnet is available in an intravenous form only and should be managed with the assistance of an infectious disease consultant.

Use should be reserved for patients who have failed first-line therapies and when other treatment options are not available. Laboratory confirmation of aciclovir-resistant HSV is recommended.

Primary options

foscarnet: 40 mg/kg intravenously every 8-12 hours for 2-3 weeks

Consider – symptomatic treatment

Back
ACUTE
|
genital disease: first episode, immunocompromised, non-pregnant
Consider – 

symptomatic treatment

Additional treatment recommended for SOME patients in selected patient group

Prompt initiation of oral antiviral therapy provides the most effective and safe symptomatic treatment available.

Analgesics and sitz baths, in which the affected genital area is immersed in warm water, can decrease pain associated with severe or prolonged recurrences.[9] External dysuria may also be alleviated by urinating with the genitals submerged in water.

If additional symptom relief is required, topical lidocaine may be used to manage pain, especially that associated with first-episode genital herpes. Patients should be made aware that lidocaine is associated with allergic reactions.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: 400-600 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

lidocaine topical: (5% ointment) apply to the affected area(s) two to three times daily when required

genital disease: recurrent episode, immunocompetent, non-pregnant

1st line – oral antiviral therapy

Back
ACUTE
|
genital disease: recurrent episode, immunocompetent, non-pregnant
1st line – 

oral antiviral therapy

Treatment reduces the risk of neurological complications, limits the severity and duration of the disease, and provides symptomatic relief.[60] Valaciclovir, famciclovir, and aciclovir are approved for active disease.[37]

Therapy should be started within 48-72 hours of onset of signs or symptoms, or earlier if possible, with the onset of prodrome. Dosages and duration of therapy differ depending on the drug and the immune status of the host. Duration of therapy should be extended until all lesions are resolved, particularly in the immunocompromised population. Resistance to these drugs is very rare.[62]

Treatment of genital herpes with topical antiviral drugs offers minimal clinical benefit, and use is discouraged.[37] An additional concern is that topical creams may delay the healing of genital herpes recurrences.

Primary options

aciclovir: 800 mg orally twice daily for 5 days; or 400 mg three times daily for 5 days; or 800 mg three times daily for 2 days

OR

valaciclovir: 500 mg orally twice daily for 3 days; or 1000 mg once daily for 5 days

OR

famciclovir: 125 mg orally twice daily for 5 days; or 1000 mg twice daily for 1 day; or 500 mg as a single dose, then 250 mg twice daily for 2 days

Consider – symptomatic treatment

Back
ACUTE
|
genital disease: recurrent episode, immunocompetent, non-pregnant
Consider – 

symptomatic treatment

Additional treatment recommended for SOME patients in selected patient group

Prompt initiation of oral antiviral therapy provides the most effective and safe symptomatic treatment available.

Analgesics and sitz baths, in which the affected genital area is immersed in warm water, can decrease pain associated with severe or prolonged recurrences.[9] External dysuria may also be alleviated by urinating with the genitals submerged in water.

If additional symptom relief is required, topical lidocaine may be used to manage pain, especially that associated with first-episode genital herpes. Patients should be made aware that lidocaine is associated with allergic reactions.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: 400-600 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

lidocaine topical: (5% ointment) apply to the affected area(s) two to three times daily when required

genital disease: recurrent episode, immunocompromised, non-pregnant

1st line – oral antiviral therapy

Back
ACUTE
|
genital disease: recurrent episode, immunocompromised, non-pregnant
1st line – 

oral antiviral therapy

Treatment reduces the risk of neurological complications, limits the severity and duration of the disease, and provides symptomatic relief.[60] Valaciclovir, famciclovir, and aciclovir are approved for active disease.[37]

Therapy should be started within 48-72 hours of onset of signs or symptoms, or earlier if possible, with the onset of prodrome. Dosages and duration of therapy differ depending on the drug and the immune status of the host. Duration of therapy should be extended until all lesions are resolved, particularly in the immunocompromised population. Resistance to these drugs is very rare.[62]

Treatment of genital herpes with topical antiviral drugs offers minimal clinical benefit, and use is discouraged.[37] An additional concern is that topical creams may delay the healing of genital herpes recurrences.

Primary options

aciclovir: 400 mg orally three times daily for 5-10 days

OR

valaciclovir: 1000 mg orally twice daily for 5-10 days

OR

famciclovir: 500 mg orally twice daily for 5-10 days

Consider – symptomatic treatment

Back
ACUTE
|
genital disease: recurrent episode, immunocompromised, non-pregnant
Consider – 

symptomatic treatment

Additional treatment recommended for SOME patients in selected patient group

Prompt initiation of oral antiviral therapy provides the most effective and safe symptomatic treatment available.

Analgesics and sitz baths, in which the affected genital area is immersed in warm water, can decrease pain associated with severe or prolonged recurrences.[9] External dysuria may also be alleviated by urinating with the genitals submerged in water.

If additional symptom relief is required, topical lidocaine may be used to manage pain, especially that associated with first-episode genital herpes. Patients should be made aware that lidocaine is associated with allergic reactions.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: 400-600 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

lidocaine topical: (5% ointment) apply to the affected area(s) two to three times daily when required

2nd line – foscarnet

Back
ACUTE
|
genital disease: recurrent episode, immunocompromised, non-pregnant
2nd line – 

foscarnet

Foscarnet is available in an intravenous form only and should be managed with the assistance of an infectious disease consultant.

Use should be reserved for patients who have failed first-line and when other treatment options are not available. Laboratory confirmation of aciclovir-resistant HSV is recommended.

Primary options

foscarnet: 40 mg/kg intravenously every 8-12 hours for 2-3 weeks

Consider – symptomatic treatment

Back
ACUTE
|
genital disease: recurrent episode, immunocompromised, non-pregnant
Consider – 

symptomatic treatment

Additional treatment recommended for SOME patients in selected patient group

Prompt initiation of oral antiviral therapy provides the most effective and safe symptomatic treatment available.

Analgesics and sitz baths, in which the affected genital area is immersed in warm water, can decrease pain associated with severe or prolonged recurrences.[9] External dysuria may also be alleviated by urinating with the genitals submerged in water.

If additional symptom relief is required, topical lidocaine may be used to manage pain, especially that associated with first-episode genital herpes. Patients should be made aware that lidocaine is associated with allergic reactions.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: 400-600 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

lidocaine topical: (5% ointment) apply to the affected area(s) two to three times daily when required

genital disease: primary or first-episode, pregnant

1st line – oral antiviral therapy

Back
ACUTE
|
genital disease: primary or first-episode, pregnant
1st line – 

oral antiviral therapy

At the time of the initial outbreak, antiviral treatment should be administered orally to reduce the duration and the severity of the symptoms and viral shedding. Treatment may be extended if healing is incomplete after 10 days of therapy.

Pregnant patients with a clinical history of genital herpes should also be offered suppressive viral therapy at or beyond 36 weeks of gestation.[37]

Primary options

aciclovir: 400 mg orally three times daily for 7-10 days

OR

valaciclovir: 1000 mg orally twice daily for 7-10 days

genital disease: recurrent episode, pregnant

1st line – oral antiviral therapy

Back
ACUTE
|
genital disease: recurrent episode, pregnant
1st line – 

oral antiviral therapy

Therapy should be started within 48-72 hours of onset of signs or symptoms, or earlier if possible, with the onset of prodrome.

Pregnant patients with a clinical history of genital herpes should also be offered suppressive viral therapy at or beyond 36 weeks of gestation.[37]

Primary options

aciclovir: 400 mg orally three times daily for 5 days; or 800 mg orally twice daily for 5 days

OR

valaciclovir: 500 mg orally twice daily for 3 days; or 1000 mg orally once daily for 5 days

oral disease: first episode, immunocompetent

1st line – oral antiviral therapy

Back
ACUTE
|
oral disease: first episode, immunocompetent
1st line – 

oral antiviral therapy

Therapy for the first episode is the most critical and should be provided for all patients. Treatment reduces the risk of neurological complications, limits the severity and duration of the disease, and provides symptomatic relief.[60]

Therapy should be started within 48-72 hours of onset of signs or symptoms. Dosages and duration of therapy differ depending on the drug and the immune status of the host. Duration of therapy should be extended until all lesions are resolved, particularly in the immunocompromised population. Resistance to these drugs is very rare.[62]

Primary options

aciclovir: 400 mg orally three times daily for 5-10 days

OR

valaciclovir: 1000 mg orally twice daily for 7-10 days

OR

famciclovir: 500 mg orally twice daily for 7-10 days; or 250 mg orally three times daily for 7-10 days

Consider – symptomatic treatment

Back
ACUTE
|
oral disease: first episode, immunocompetent
Consider – 

symptomatic treatment

Additional treatment recommended for SOME patients in selected patient group

Prompt initiation of oral antiviral therapy provides the most effective and safe symptomatic treatment available.

Analgesics can decrease pain associated with severe or prolonged recurrences.[9] If additional symptom relief is required, topical lidocaine may be used to manage pain. Patients should be made aware that lidocaine is associated with allergic reactions.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: 400-600 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

lidocaine topical: (5% ointment) apply to the affected area(s) two to three times daily when required

2nd line – topical antiviral therapy

Back
ACUTE
|
oral disease: first episode, immunocompetent
2nd line – 

topical antiviral therapy

The use of topical therapy for cold sores is not recommended. Oral therapy is preferred for treatment of recurrent herpes simplex labialis over topical antiviral creams. Some patients may prefer the use of antiviral creams due to the lack of required prescription and the ability to avoid oral medication. Antiviral creams have a small but statistically significant effect on the duration of cold sores.

Docosanol cream may reduce healing time of cold sores by 18 hours to 3 days compared with placebo when applied at the start of oral herpes recurrence (tingling sensation or redness).[53][54]

Penciclovir cream shortens the duration of herpes simplex labialis recurrences by 0.7 days when applied every 2 hours while awake compared with placebo.[55] The duration of pain and viral shedding were also significantly decreased with the use of penciclovir cream.

Aciclovir cream decreases herpes simplex labialis outbreaks by 0.5 days.[56]

Primary options

docosanol topical: (10%) apply to the affected area(s) five times daily at first sign of symptoms

OR

penciclovir topical: (1%) apply to the affected area(s) every 2 hours

OR

aciclovir topical: (5%) apply to affected area(s) five times daily

Consider – symptomatic treatment

Back
ACUTE
|
oral disease: first episode, immunocompetent
Consider – 

symptomatic treatment

Additional treatment recommended for SOME patients in selected patient group

Prompt initiation of oral antiviral therapy provides the most effective and safe symptomatic treatment available.

Analgesics can decrease pain associated with severe or prolonged recurrences.[9] If additional symptom relief is required, topical lidocaine may be used to manage pain. Patients should be made aware that lidocaine is associated with allergic reactions.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: 400-600 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

lidocaine topical: (5% ointment) apply to the affected area(s) two to three times daily when required

oral disease: first episode, immunocompromised

1st line – oral antiviral therapy

Back
ACUTE
|
oral disease: first episode, immunocompromised
1st line – 

oral antiviral therapy

Therapy for the first episode is the most critical and should be provided for all patients. Treatment reduces the risk of neurological complications, limits the severity and duration of the disease, and provides symptomatic relief.[60]

Therapy should be started within 48-72 hours of onset of signs or symptoms. Dosages and duration of therapy differ depending on the drug and the immune status of the host. Duration of therapy should be extended until all lesions are resolved, particularly in the immunocompromised population. Resistance to these drugs is very rare.[62]

Primary options

aciclovir: 400 mg orally three times daily for 5-10 days

OR

valaciclovir: 1000 mg orally twice daily for 5-10 days

OR

famciclovir: 500 mg orally twice daily for 5-10 days

Consider – symptomatic treatment

Back
ACUTE
|
oral disease: first episode, immunocompromised
Consider – 

symptomatic treatment

Additional treatment recommended for SOME patients in selected patient group

Prompt initiation of oral antiviral therapy provides the most effective and safe symptomatic treatment available.

Analgesics can decrease pain associated with severe or prolonged recurrences.[9] If additional symptom relief is required, topical lidocaine may be used to manage pain. Patients should be made aware that lidocaine is associated with allergic reactions.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: 400-600 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

lidocaine topical: (5% ointment) apply to the affected area(s) two to three times daily when required

2nd line – topical antiviral therapy

Back
ACUTE
|
oral disease: first episode, immunocompromised
2nd line – 

topical antiviral therapy

The use of topical therapy for cold sores is not recommended. Oral therapy is preferred for treatment of recurrent herpes simplex labialis over topical antiviral creams. Some patients may prefer the use of antiviral creams due to the lack of required prescription and the ability to avoid oral medication. Antiviral creams have a small but statistically significant effect on the duration of cold sores.

Docosanol cream may reduce healing time of cold sores by 18 hours to 3 days compared with placebo when applied at the start of oral herpes recurrence (tingling sensation or redness).[53][54]

Penciclovir cream shortens the duration of herpes simplex labialis recurrences by 0.7 days when applied every 2 hours while awake compared with placebo.[55] The duration of pain and viral shedding were also significantly decreased with the use of penciclovir cream.

Aciclovir cream decreases herpes simplex labialis outbreaks by 0.5 days.[56]

Primary options

docosanol topical: (10%) apply to the affected area(s) five times daily at first sign of symptoms

OR

penciclovir topical: (1%) apply to the affected area(s) every 2 hours

OR

aciclovir topical: (5%) apply to affected area(s) five times daily

Consider – symptomatic treatment

Back
ACUTE
|
oral disease: first episode, immunocompromised
Consider – 

symptomatic treatment

Additional treatment recommended for SOME patients in selected patient group

Prompt initiation of oral antiviral therapy provides the most effective and safe symptomatic treatment available.

Analgesics can decrease pain associated with severe or prolonged recurrences.[9] If additional symptom relief is required, topical lidocaine may be used to manage pain. Patients should be made aware that lidocaine is associated with allergic reactions.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: 400-600 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

lidocaine topical: (5% ointment) apply to the affected area(s) two to three times daily when required

oral disease: recurrent episode, immunocompetent

1st line – oral antiviral therapy

Back
ACUTE
|
oral disease: recurrent episode, immunocompetent
1st line – 

oral antiviral therapy

Treatment reduces the risk of neurological complications, limits the severity and duration of the disease, and provides symptomatic relief.[60]

Therapy should be started within 48-72 hours of onset of signs or symptoms. Dosages and duration of therapy differ depending on the drug and the immune status of the host. Duration of therapy should be extended until all lesions are resolved, particularly in the immunocompromised population. Resistance to these drugs is very rare.[62]

Primary options

aciclovir: 400 mg orally three times daily for 5-10 days

OR

valaciclovir: 2000 mg orally twice daily for 1 day

OR

famciclovir: 1500 mg orally once daily for 1 day

Consider – symptomatic treatment

Back
ACUTE
|
oral disease: recurrent episode, immunocompetent
Consider – 

symptomatic treatment

Additional treatment recommended for SOME patients in selected patient group

Prompt initiation of oral antiviral therapy provides the most effective and safe symptomatic treatment available.

Analgesics can decrease pain associated with severe or prolonged recurrences.[9] If additional symptom relief is required, topical lidocaine may be used to manage pain. Patients should be made aware that lidocaine is associated with allergic reactions.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: 400-600 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

lidocaine topical: (5% ointment) apply to the affected area(s) two to three times daily when required

2nd line – topical antiviral therapy

Back
ACUTE
|
oral disease: recurrent episode, immunocompetent
2nd line – 

topical antiviral therapy

The use of topical therapy for cold sores is not recommended. Oral therapy is preferred for treatment of recurrent herpes simplex labialis over topical antiviral creams. Some patients may prefer the use of antiviral creams due to the lack of required prescription and the ability to avoid oral medication. Antiviral creams have a small but statistically significant effect on the duration of cold sores.

Docosanol cream may reduce healing time of cold sores by 18 hours to 3 days compared with placebo when applied at the start of oral herpes recurrence (tingling sensation or redness).[53][54]

Penciclovir cream shortens the duration of herpes simplex labialis recurrences by 0.7 days when applied every 2 hours while awake compared with placebo.[55] The duration of pain and viral shedding were also significantly decreased with the use of penciclovir cream.

Aciclovir cream decreases herpes simplex labialis outbreaks by 0.5 days.[56]

Primary options

docosanol topical: (10%) apply to the affected area(s) five times daily at first sign of symptoms

OR

penciclovir topical: (1%) apply to the affected area(s) every 2 hours

OR

aciclovir topical: (5%) apply to affected area(s) five times daily

Consider – symptomatic treatment

Back
ACUTE
|
oral disease: recurrent episode, immunocompetent
Consider – 

symptomatic treatment

Additional treatment recommended for SOME patients in selected patient group

Prompt initiation of oral antiviral therapy provides the most effective and safe symptomatic treatment available.

Analgesics can decrease pain associated with severe or prolonged recurrences.[9] If additional symptom relief is required, topical lidocaine may be used to manage pain. Patients should be made aware that lidocaine is associated with allergic reactions.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: 400-600 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

lidocaine topical: (5% ointment) apply to the affected area(s) two to three times daily when required

oral disease: recurrent episode, immunocompromised

1st line – oral antiviral therapy

Back
ACUTE
|
oral disease: recurrent episode, immunocompromised
1st line – 

oral antiviral therapy

Treatment reduces the risk of neurological complications, limits the severity and duration of the disease, and provides symptomatic relief.[60]

Therapy should be started within 48-72 hours of onset of signs or symptoms. Dosages and duration of therapy differ depending on the drug and the immune status of the host. Duration of therapy should be extended until all lesions are resolved, particularly in the immunocompromised population. Resistance to these drugs is very rare.[62]

Primary options

aciclovir: 400 mg orally three times daily for 5-10 days

OR

valaciclovir: 1000 mg orally twice daily for 5-10 days

OR

famciclovir: 500 mg orally twice daily for 5-10 days

Consider – symptomatic treatment

Back
ACUTE
|
oral disease: recurrent episode, immunocompromised
Consider – 

symptomatic treatment

Additional treatment recommended for SOME patients in selected patient group

Prompt initiation of oral antiviral therapy provides the most effective and safe symptomatic treatment available.

Analgesics can decrease pain associated with severe or prolonged recurrences.[9] If additional symptom relief is required, topical lidocaine may be used to manage pain. Patients should be made aware that lidocaine is associated with allergic reactions.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: 400-600 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

lidocaine topical: (5% ointment) apply to the affected area(s) two to three times daily when required

2nd line – topical antiviral therapy

Back
ACUTE
|
oral disease: recurrent episode, immunocompromised
2nd line – 

topical antiviral therapy

The use of topical therapy for cold sores is not recommended. Oral therapy is preferred for treatment of recurrent herpes simplex labialis over topical antiviral creams. Some patients may prefer the use of antiviral creams due to the lack of required prescription and the ability to avoid oral medication. Antiviral creams have a small but statistically significant effect on the duration of cold sores.

Docosanol cream may reduce healing time of cold sores by 18 hours to 3 days compared with placebo when applied at the start of oral herpes recurrence (tingling sensation or redness).[53][54]

Penciclovir cream shortens the duration of herpes simplex labialis recurrences by 0.7 days when applied every 2 hours while awake compared with placebo.[55] The duration of pain and viral shedding were also significantly decreased with the use of penciclovir cream.

Aciclovir cream decreases herpes simplex labialis outbreaks by 0.5 days.[56]

Primary options

docosanol topical: (10%) apply to the affected area(s) five times daily at first sign of symptoms

OR

penciclovir topical: (1%) apply to the affected area(s) every 2 hours

OR

aciclovir topical: (5%) apply to affected area(s) five times daily

Consider – symptomatic treatment

Back
ACUTE
|
oral disease: recurrent episode, immunocompromised
Consider – 

symptomatic treatment

Additional treatment recommended for SOME patients in selected patient group

Prompt initiation of oral antiviral therapy provides the most effective and safe symptomatic treatment available.

Analgesics can decrease pain associated with severe or prolonged recurrences.[9] If additional symptom relief is required, topical lidocaine may be used to manage pain. Patients should be made aware that lidocaine is associated with allergic reactions.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: 400-600 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

lidocaine topical: (5% ointment) apply to the affected area(s) two to three times daily when required

3rd line – foscarnet

Back
ACUTE
|
oral disease: recurrent episode, immunocompromised
3rd line – 

foscarnet

Foscarnet is available in an intravenous form only and should be managed with the assistance of an infectious disease consultant.

Use should be reserved for patients who have failed first-line therapies and when other treatment options are not available. Laboratory confirmation of aciclovir-resistant HSV is recommended.

Primary options

foscarnet: 40 mg/kg intravenously every 8-12 hours for 2-3 weeks

Consider – symptomatic treatment

Back
ACUTE
|
oral disease: recurrent episode, immunocompromised
Consider – 

symptomatic treatment

Additional treatment recommended for SOME patients in selected patient group

Prompt initiation of oral antiviral therapy provides the most effective and safe symptomatic treatment available.

Analgesics can decrease pain associated with severe or prolonged recurrences.[9] If additional symptom relief is required, topical lidocaine may be used to manage pain. Patients should be made aware that lidocaine is associated with allergic reactions.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: 400-600 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

lidocaine topical: (5% ointment) apply to the affected area(s) two to three times daily when required

ONGOING

genital disease: sexually active or frequent severe recurrences, immunocompetent, non-pregnant

1st line – suppressive antiviral therapy

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ONGOING
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genital disease: sexually active or frequent severe recurrences, immunocompetent, non-pregnant
1st line – 

suppressive antiviral therapy

Daily suppressive therapy may be offered for patients wishing to prevent recurrences, and may be considered for HIV-uninfected patients with genital herpes who wish to decrease the risk of transmission to sexual partners.[50][57]​ The need for suppressive therapy should be re-evaluated on a yearly basis.

Primary options

aciclovir: 400 mg orally twice daily for 12 months

OR

valaciclovir: 500-1000 mg orally once daily for 12 months

OR

famciclovir: 250 mg orally twice daily for 12 months

genital disease: sexually active or frequent severe recurrences, immunocompromised, non-pregnant

1st line – suppressive antiviral therapy

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ONGOING
|
genital disease: sexually active or frequent severe recurrences, immunocompromised, non-pregnant
1st line – 

suppressive antiviral therapy

Daily suppressive therapy may be offered to those wishing to prevent recurrence. The need for suppressive therapy should be re-evaluated on a yearly basis. Suppressive therapy also reduces the risk of transmission to sexual partners.

Primary options

aciclovir: 400-800 mg orally twice to three times daily for 12 months

OR

valaciclovir: 500 mg orally twice daily for 12 months

OR

famciclovir: 500 mg orally twice daily for 12 months

genital disease: pregnant

1st line – suppressive antiviral therapy + consider caesarean delivery

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ONGOING
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genital disease: pregnant
1st line – 

suppressive antiviral therapy + consider caesarean delivery

Suppressive therapy should be offered to pregnant women with a first-episode outbreak of genital herpes infection during early pregnancy, or women with a prior clinical history of HSV-2. Prophylaxis should start at 36 weeks' estimated gestational age until delivery to reduce the risk of HSV shedding, genital herpes recurrence at delivery, and the need for caesarean delivery for genital herpes. For women with a first-episode genital HSV infection during the third trimester of pregnancy, caesarean delivery may be offered due to the possibility of prolonged viral shedding.[48][63][64][65]

Primary options

aciclovir: 400 mg orally three times daily

OR

valaciclovir: 500 mg orally twice daily

oral disease: frequent severe recurrences, immunocompetent

1st line – suppressive antiviral therapy

Back
ONGOING
|
oral disease: frequent severe recurrences, immunocompetent
1st line – 

suppressive antiviral therapy

Daily suppressive therapy may be offered for persons wishing to prevent recurrences, especially those with frequent severe recurrences. Patient preference is a key factor in making this decision. The need for suppressive therapy should be re-evaluated on a yearly basis.

Primary options

aciclovir: 400 mg orally twice daily for 12 months

OR

valaciclovir: 500-1000 mg orally once daily for 12 months

OR

famciclovir: 250 mg orally twice daily for 12 months

oral disease: frequent severe recurrences, immunocompromised

1st line – suppressive antiviral therapy

Back
ONGOING
|
oral disease: frequent severe recurrences, immunocompromised
1st line – 

suppressive antiviral therapy

Daily suppressive therapy may be offered for persons wishing to prevent recurrences, especially those with frequent severe recurrences. Patient preference is a key factor in making this decision. The need for suppressive therapy should be re-evaluated on a yearly basis.

Primary options

aciclovir: 400 mg orally twice to three times daily for 12 months

OR

valaciclovir: 500 mg orally twice daily for 12 months

OR

famciclovir: 500 mg orally twice daily for 12 months

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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