Oropharyngeal Herpes Simplex Infection in Adults - Guideline for the management of
|Last review: 07/02/2019|
|Next review: 07/02/2022|
|Approved By: Improving Antimicrobial Prescribing Group|
|Copyright© Leeds Teaching Hospitals NHS Trust 2019|
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
Guideline for the management of Oropharyngeal Herpes Simplex Infection in Adults
Oropharyngeal Herpes Simplex Infection in Adults
Criteria for use of guidelines
The treatment of herpes simplex infection is largely based on the use of various nucleoside derivatives that interfere with the synthesis of viral DNA.
Treatment of uncomplicated oropharyngeal disease
Studies with Aciclovir 5% cream demonstrated small but statistically significant reduction in pain and lesion duration when administered within 1 hr of onset and then five times a day for 4 days compared with placebo. Duration of lesion episode < 1 day.¹
Penciclovir 1% administered up to six times a day for first day and then every 2hr for 4 days small, significant improvement in lesion healing.³ Compared with Aciclovir non-significant - similar efficacy, clinical cure rates, but penciclovir shorter time to resolution 4.
There have been no trials directly comparing the newer antivirals with Aciclovir . There have, however, been a few placebo controlled studies. Significantly more work has been done in the area of genital herpetic infection. Valaciclovir is superior to placebo in reactivation of HSV if given in the prodromal phase of the illness. Famciclovir is also superior to placebo. Both can be given in very short courses.
There has been a large randomised, double blind, placebo – controlled trial of valaciclovir in North America which led to the licensing of valaciclovir in the treatment of oropharyngeal herpes in the USA. They showed that short course valaciclovir when given early in the course of disease, during the prodrome and prior to any clinical signs significantly reduces the duration of the episode and the time to cessation of pain/discomfort was also significantly reduced. They showed no difference between using 2g 12 hourly for 2 doses and 2g bd for 24 hours followed by 1g bd. 7 A second study, also by Spruance showed Famciclovir (single dose of 1500mg) to reduce the healing time of lesions when compared with placebo. 8 Evidence level D
There have been no trials looking at either of these agents in primary infection.
Treatment in the immunocompromised host
A further placebo controlled trial (not randomised) shows a significant difference between Famciclovir and placebo in reduction of HSV shedding and symptomatology in HIV infected patients. This was seen in both anogenital infection and oropharyngeal infection. 10 Evidence level D
In view of the possible increased pill burden in immunocompromised patients and the perceived concept that adherence may be poorer, and the consequences of such non adherence will be more significant, it may be sensible to use valaciclovir in this situation. However, there is no evidence to suggest that this is more effective than Aciclovir .
The role of prophylaxis of recurrent herpes simplex infection is beyond the scope of this guideline. Seek expert opinion in such cases.
Oropharyngeal Herpes Simplex
|Target patient group:||Adults|
|Target professional group(s):||Pharmacists
Secondary Care Doctors
- Spruance et al. Aciclovir cream for treatment of herpes simple labialis; results of two randomised , double-blind vehicle controlled, multicentre clinical trials. Antimicrobial agents and chemotherapy Jul 2002;vol 46; no 7 2238-43
- Fiddian AP et al. Successful treatment of herpes labilais with topical aciclovir. Br. Med J 1983:286:1699-701
- Raboren et al. Effective treatment of herpes simplex labialis with peniclovir cream: combined results of two trials. Journal of the American dental Association 2002;133;309-9
- Lin et al. Topical application of peniclovir cream for the treatment of herpes simplex facialis/labialis: a randomized, double-blind, multicentre, acyclovir controlled trial. The journal of dermatological treatment 2002:13:67-72
- A Jensen, J. D Hoehns, and C. L Squires Oral Antivirals for the Acute Treatment of Recurrent Herpes Labialis. Ann. Pharmacother., April 1, 2004; 38(4): 705 - 709.
- Simmons A. Clinical manifestations and treatment considerations of herpes simplex virus infection. J Inf. Dis 2002:186: p S71
- Spruance, LS et al; High-Dose, Short-Duration, Early Valacyclovir Therapy for Episodic Treatment of Cold Sores: Results of Two Randomized, Placebo-Controlled, Multicenter Studies. Antimicrob Agents Chemotherapy 2003 March 47(3): 1072-1080
- Spruance, LS et al; Single dose, patient initiated famciclovir: a randomised, double blind, placebo- controlled trial for episodic treatment of herpes labialis. Journal of the Am Academy of Dermatology. 2006, 55(1): 47-53.
- Eisen et al; Clinical utility of oral valacyclovir compared with iral acyclovir for the prevention of herpes simplex virus mucositis following autologous bone marrow transplantation or stem cell rescue therapy. Bone marrow transplantation (2003) 31:51-55.
- Schacker, T; Famciclovir for the suppression of symptomatic and asymptomatic herpes simplex virus reactivation in HIV infected persons: a double blind, placebo-controlled trial. Annals if Internal Medicine 1998; 128(1):21-28.
- Amir J, Harel L, Smetana Z, Varsano I. Treatment of herpes simplex gingivostomatitis with aciclovir in children: a randomised double blind placebo controlled study. BMJ. 1997;314:1800-1803
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. LTHT consensus.
Improving Antimicrobial Prescribing Group
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