Herpes Simplex Virus (HSV) in Emergency Medicine Medication

Updated: Jul 16, 2019
  • Author: Melissa Kohn, MD, MS, FACEP, EMT-PHP; Chief Editor: Steven C Dronen, MD, FAAEM  more...
  • Print

Medication Summary

Antiviral drugs with activity against viral DNA synthesis have been effective against HSV infections. These drugs inhibit virus replication and may suppress clinical manifestations but are not a cure for the disease. Since HSV remains latent in sensory ganglia, the rates of relapse are similar in treated and untreated patients.

The 2015 CDC guidelines for STD treatment recommend that all initial genital herpes infections be treated with antivirals to reduce any potential complications. [15, 17]

Acyclovir (Zovirax) provides initial, recurrent, and suppressive therapy for genital HSV. It is effective for mucocutaneous HSV in an immunocompromised host as well as HSV encephalitis. Little evidence supports the routine use of acyclovir for primary oral-labial HSV. Oral acyclovir has been shown to be effective in suppressing herpes labialis in immunocompromised patients with frequent recurrent infections. Begin use during the prodromal period.

Daily suppressive therapy has shown to be 80% effective in preventing recurrences and should be considered in patients who suffer from frequent recurrences. [18]

Administer famciclovir (Famvir) or valacyclovir (Valtrex) for recurrent episodes of genital HSV. Herpes simplex keratoconjunctivitis is treated with topical 1% trifluridine (Viroptic) or ganciclovir (Zirgan). [19]

In pregnancy, the use of antiviral agents such as valacyclovir and acyclovir has been shown to be safe with no increased risk of birth defects. [20]

Use pain medication as needed, such as ibuprofen or acetaminophen. Topical anesthetics may provide some relief from pain and itching. [21] Some patients may require narcotics for the relief of severe pain from the lesions.


Antiviral agents

Class Summary

The goals in use of antivirals are to (1) shorten the clinical course, (2) prevent complications, (3) prevent the development of latency and/or subsequent recurrences, (4) decrease transmission, and (5) eliminate established latency.

Acyclovir (Zovirax)

DOC; reduces duration of symptomatic lesions. Indicated for patients presenting within 48 h of rash onset. Patients on acyclovir experience less pain and faster resolution of cutaneous lesions.

Famciclovir (Famvir)

Prodrug that, when biotransformed into active metabolite penciclovir, may inhibit viral DNA synthesis/replication. Useful for recurrent episodes of genital HSV.

Valacyclovir (Valtrex)

Prodrug that is rapidly converted to acyclovir before exerting its antiviral activity. Valacyclovir is more expensive but has more convenient dosing regimen than acyclovir. Useful for recurrent episodes of genital HSV.

1% Trifluridine (Viroptic)

Replaces thymidine in viral DNA, resulting in production of defective proteins and thus inhibiting viral replication. Useful in treatment of keratoconjunctivitis.

Docosanol cream (Abreva)

Prevents viral entry and replication at cellular level. Use at first sign of cold sore or fever blister.

Ganciclovir ophthalmic (Vitrasert, Zirgan)

A guanosine derivative that, upon phosphorylation, inhibits DNA replication by herpes simplex viruses (HSV). Works by inhibiting the synthesis of viral DNA in 2 ways: competitive inhibition of viral DNA-polymerase and direct incorporation into viral primer strand DNA, resulting in DNA chain termination and prevention of replication. Useful for HSV keratitis.