Background Information

For more information, see the monograph:

The Management of HSV-1 and Ocular HSV Diseases

Gingivostomatitis
Transmission and prevention of infection

• To avoid transmitting HSV-1 infection to children, adults with active herpes labialis (fever blisters or cold sores) should not kiss children (Category 3 recommendation)*

Treatment of HSV gingivostomatitis

• Symptomatic management of HSV gingivostomatitis is required for all patients (Category 1 recommendation)

Antiviral treatment

• All children with HSV gingivostomatitis should be given oral aciclovir 15 mg/kg (to a maximum dose of 200 mg) five times daily for 5 days at the earliest signs of infection (Category 1 recommendation)

• Intravenous aciclovir should be used for severe gingivostomatitis or for hospitalized patients (Category 3 recommendation)

Antiviral prophylaxis

• Strategies for the prevention of HSV-1 infection in daycare centres remain to be decided (Research need recommendation)

Recurrent Herpes Labialis
Virus shedding and transmission of HSV-1

• Persons with active orofacial lesions should avoid kissing (oral-oral contact) and oral sex (orogenital contact) to prevent transmission of HSV-1 (Category 3 recommendation)

Trigger factors

• The likelihood of herpes labialis recurrences can be reduced by avoiding known trigger factors (e.g. trauma, stress, ultraviolet [UV] radiation) (Category 2 recommendation)

• The use of a sunscreen may prevent UV-triggered recurrences of herpes labialis (Category 2 recommendation)

Acute episodic therapy
Topical therapy

• Topical therapy with aciclovir cream (five times daily for 4 days) or penciclovir cream (2-hourly during the day for 4 days) can be used to shorten the duration of signs and symptoms of herpes labialis (Category 1 recommendation

Oral therapy

• For acute treatment, oral aciclovir (200–400 mg five times daily for 5 days), famciclovir (500 mg three times daily for 5 days), or valaciclovir (2000 mg twice daily for 1 day), should be used to shorten the duration of herpes labialis (Category 1/2 recommendation)

• Combination therapy with famciclovir 500 mg three times daily plus topical 0.05% fluocinonide gel twice daily for 5 days may be used to decrease lesion severity (Category 3 recommendation)

Continuous suppressive therapy

• Long-term antiviral prophylaxis with oral aciclovir 400 mg twice daily, or valaciclovir 500 mg once daily, should be offered to prevent recurrences of herpes labialis in patients with severe and/or frequent disease (Category 2 recommendation)

• Topical agents are ineffective for prophylaxis of herpes labialis and should be avoided (Category 2 recommendation).

*Please refer to Recommendation and Statement Categories (page 3) of the monograph The Management of HSV-1 and Ocular HSV Diseases for an explanation of the recommendations and statements.

For more information, see the monograph:

The Management of HSV-1 and Ocular HSV Diseases

Diagnosis of Genital HSV-1 Infection

• Typing should be used to confirm a diagnosis in all cases of genital herpes. This information helps to identify the source of infection and give guidance on the likely prognosis of recurrences for an individual (Category 2 recommendation)

• A test should type both HSV-1 and HSV-2, as a negative HSV-2 serological assay does not rule out genital herpes (Category 3 recommendation)

Transmission and Prevention of Genital HSV-1 Infection
Orogenital sex and transmission of HSV-1

• Individuals should avoid orogenital or skin-to-skin contact with active herpetic lesions in order to reduce the risk of acquisition of HSV-1 (or HSV-2) infection (Category 2 recommendation)

• More education (of patients and their physicians) is needed on safer oral sex practices and condom effectiveness to reduce the risk of HSV transmission (Category 3 recommendation)

Maternal Genital HSV-1 Infections and the Risk to the Neonate

• Women seropositive for HSV-1 only are at risk for primary infection with HSV-2 and thus have a risk of transmitting neonatal herpes to their infant (Category 2 recommendation)

• For at-risk women (HSV seronegative or HSV-1 seropositive; HSV seronegative) with HSV-1 or HSV-2 seropositive partners, any contact with active herpetic lesions should be avoided in pregnancy, particularly during the last trimester (Category 2 recommendation)

• The value of serological screening for HSV infection in pregnant women and their partners needs further discussion (Research need recommendation).

Management of Genital HSV-1 Infection 

• Primary, episodic and suppressive therapy for genital HSV-1 infection should follow the guidelines for management of genital HSV-2 infection (Category 1 recommendation)

• Although patients with genital HSV-1 infection are less likely to have recurrences than individuals with genital HSV-2 infection, suppressive therapy may be appropriate, especially for those whose recurrences carry a high level of morbidity (Category 2 recommendation)

• Further education is needed on safer oral sex practices and condom effectiveness for the prevention of HSV-1 transmission (Category 3 recommendation).
  
  

For more information, see the monograph:

The Management of HSV-1 and Ocular HSV Diseases

Erythema Multiforme
Characteristics and diagnosis of erythema multiforme

• Erythema multiforme is usually diagnosed clinically. Serological confirmation of HSV-1 infection need only performed if a patient fails to respond to antiviral treatment (Category 3 recommendation)

Prevention of recurrent erythema multiforme

• Photoprotection of the skin is advised to prevent erythema multiforme outbreaks triggered by UV radiation (Category 3 recommendation)

Episodic treatment of erythema multiforme

• Episodes of erythema multiforme should be treated symptomatically (Category 2 recommendation)

• In retrospective studies, oral aciclovir administered at the first signs and symptoms was effective in reducing the duration of erythema multiforme in adults but not in children. The utility of antiviral therapy for the episodic treatment of erythema multiforme needs to be established in a randomized, double-blind, placebo-controlled trial (Research need recommendation)

Symptomatic management of erythema multiforme

Antiviral prophylaxis for recurrent erythema multiforme
Aciclovir

• Aciclovir 400 mg twice daily for 6 months should be offered as suppression for recurrent erythema multiforme (four minor episodes/year or two major episodes/year,depending on the patient’s level of distress) (Category 1 recommendation)

Valaciclovir and famciclovir

• Valaciclovir (500 mg twice daily) is recommended in cases of erythema multiforme unresponsive to aciclovir (Category 3 recommendation)

Eczema Herpeticum
Prevention of recurrences

• The risk of eczema herpeticum recurrences may be reduced by avoiding excessive sun exposure or using a sunblock (Category 3 recommendation).

Transmission of HSV-1 in patients with atopic dermatitis

• Individuals with atopic dermatitis, who are at risk of eczema herpeticum, should avoid skin-to-skin contact with people who have active herpes lesions (especially orofacial lesions) (Category 3 recommendation)

Treatment of eczema herpeticum

• Mild eczema herpeticum should be treated with oral aciclovir 200 mg five times daily for 5 days (Category 2 recommendation)

• Treatment of severe eczema herpeticum

• Severe eczema herpeticum should be treated with intravenous aciclovir 5 mg/kg 8-hourly for 10 days (Category 2 recommendation)

Symptomatic care

• The utility of local skin care antiseptic washes and saline washes for the symptomatic management of eczema herpeticum requires further study (Research need recommendation)

Herpes Simplex Encephalitis
PCR analysis of CSF for diagnosis of HSV encephalitis

• PCR analysis of CSF should be used to diagnose HSV encephalitis (Category 1 recommendation)

Intravenous treatment for HSV encephalitis

• The recommended treatment for HSV encephalitis in adults and children older than 3 months of age is intravenous aciclovir (10 mg/kg every 8 hours for 14–21 days)(Category 1 recommendation)

Herpes Gladiatorum
Transmission of herpes gladiatorum

• All athletes who play contact sports with likely skin-to-skin contact should be screened for herpes gladiatorum prior to practice and competitive events (Category 2 recommendation)

• Any athlete with open lesions of herpes gladiatorum should be prevented from participating in competitive events involving skin-to-skin contact until they have physician confirmation that they are disease-free (Category 2 recommendation)

Diagnosis

• A diagnosis of herpes gladiatorum should be made on the basis of clinical examination and, if necessary, by lesion swabbing for virus culture or direct fluorescent antigen test (Category 3 recommendation).

Episodic treatment of herpes gladiatorum with aciclovir

• Herpes gladiatorum should be treated with oral aciclovir (200 mg five times daily for 7–10 days), which should be administered at the first signs of prodrome (Category 3 recommendation)

Episodic treatment of herpes gladiatorum with valaciclovir or famciclovir

• Valaciclovir (500 mg twice daily) may be used in the episodic treatment of herpes gladiatorum (Category 3 recommendation)

• The efficacy of famiciclovir in the treatment of herpes gladiatorum should be investigated in a double-blind, randomized clinical trial (Research need recommendation)

Prevention of recurrences of herpes gladiatorum with valaciclovir

• Valaciclovir (1000 mg once daily or 500 mg twice daily) should be used to prevent herpes gladiatorum recurrences in patients with a history of disease of less than 2 years(Category 2 recommendation)

• Valaciclovir (500 mg once daily) should be used to prevent herpes gladiatorum recurrences in patients with a history of disease of more than 2 years (Category 2 recommendation).

• All patients undergoing facial resurfacing should be given antiviral prophylaxis (Category 2 recommendation)

Herpetic Whitlow
Prevention

• Healthcare professionals in contact with oral secretions and involved in wound care are at risk of acquiring herpetic whitlow, and as such should wear gloves during patient care (Category 3 recommendation)

Surgical intervention

• Surgical drainage of herpetic whitlow should be avoided as it may lead to disseminated disease (Category 3 recommendation)

Antiviral treatment

Treatment of established herpetic whitlow

• Aciclovir may be beneficial in the treatment of established herpetic whitlow but the optimal dose remains to be defined (Category 3 recommendation)

• Aciclovir (1600–2000 mg/day for 10 days in two or three doses) started at first signs of prodrome aborts the appearance of recurrent herpetic whitlow lesions and significantly reduces symptom duration (Category 2 recommendation)

Acute Peripheral Facial Palsy (Bell’s Palsy)
Treatment
Antiviral and corticosteroid combination therapy

• Oral aciclovir (2000 mg/day) should be used as adjunctive therapy to oral corticosteroids in the treatment of all patients with acute peripheral facial (Bell’s) palsy (Category 2 recommendation)

• Maximum benefit on outcome and recovery from acute peripheral facial (Bell’s) palsy will be achieved if combination treatment (high-dose oral aciclovir [2000 mg/day] and oral corticosteroids) is started within 3 days of symptom onset (Category 2 recommendation).

For more information, see the monograph:

The Management of HSV-1 and Ocular HSV Diseases

Routes of Ocular Infection
Neuronal route of infection

• Spread of HSV from orofacial sites to the eye indicates that aggressive treatment of a primary HSV infection (especially herpes labialis and gingivostomatitis) with oral antiviral agents would prevent ocular disease (Research need recommendation)

For more information, see the monograph:

The Management of HSV-1 and Ocular HSV Diseases

Introduction

• As ocular herpes simplex virus (HSV) disease is easily treated, rapid diagnosis and prompt treatment will reduce the morbidity and disability associated with these diseases. It is therefore recommended that physicians consider a diagnosis of HSV disease when a patient presents with any eye infection (Category 3 recommendation)

• Education and information about ocular herpesvirus infections are especially important for primary care physicians and patients (Category 3 recommendation).

For more information, see the monograph:

The Management of HSV-1 and Ocular HSV Diseases

Graft Failure Following PKP in Patients with and without a History of HSV Keratitis
Corneal graft failure and herpes simplex infection

• Ocular HSV disease should be considered as a possible cause of graft failure following penetrating keratoplasty (Category 1 recommendation)

HSV keratitis following PKP in patients without an apparent history of HSV infection

• Ophthalmologists should be aware that, although a rare event, HSV keratitis can occur unexpectedly because of a subclinical infection in past, as a result of which latency was established in the sensory innervation of the cornea. This can have serious sequalae if it is not recognized and treated appropriately (Category 2 recommendation)

Eye banks as a source of infectious HSV

• It is recommended that if endothelial damage in the form of diffuse necrotic cells in a stored cornea is identified prior to grafting, HSV should be suspected as a cause, and the tissue, together with the other donor cornea, should not be used for transplantation (Category 3 recommendation)

Screening of donor cornea culture fluid for evidence of HSV infection

• Screening of donor cornea culture fluid for evidence of HSV infection is not warranted (Category 2 recommendation)

Prophylaxis for HSV Infection Following PKP

• Prophylactic antiviral therapy (topical or oral) following PKP for ocular HSV disease should be considered for all patients, particularly those receiving immunosuppressive therapy (Category 2 recommendation)

• For patients without a history of HSV keratitis, post-operative prophylactic therapy is not warranted (Category 2 recommendation)

• The duration and optimal dose of prophylactic antiviral therapy following PKP for HSV keratitis have yet to be determined in a large-scale, randomized trial (Research need recommendation)

Concomitant use of Antiviral Therapy and Steroids

• For patients using topical corticosteroids for rejection, a long-term (oral) antiviral should be provided for prophylactic cover (Category 2 recommendation).

For more information, see the monograph:

The Management of HSV-1 and Ocular HSV Diseases

Treatment of HSV Epithelial Keratitis

• HSV epithelial keratitis should be treated with topical trifluridine, topical aciclovir or oral aciclovir (Category 2 recommendation)

Aciclovir
Oral aciclovir
Oral aciclovir for the management of HSV epithelial keratitis in children

• Oral aciclovir is likely to be a useful adjunct for the treatment of HSV epithelial keratitis in children (Category 3 recommendation)

Other agents

• The utility of ganciclovir gel (0.15%) in the treatment of HSV epithelial keratitis should be evaluated in a large-scale, double-blind randomized clinical trial (Research need recommendation)

HSV Stromal Keratitis
Episodic treatment of HSV stromal keratitis
Topical corticosteroid therapy and trifluridine

• Topical corticosteroid therapy in combination with an antiviral is recommended for the episodic treatment of HSV stromal keratitis in non-immunocompromised adults (Category 1 recommendation)

Aciclovir as an adjunct to topical corticosteroid therapy and trifluridine

• Oral aciclovir is not required as adjunctive therapy for the treatment of HSV stromal keratitis in patients receiving trifluridine and concomitant corticosteroid therapy (Category 3 recommendation)

Prevention of HSV stromal keratitis recurrences

• Oral aciclovir should be administered to patients at high risk of recurrences of HSV stromal keratitis (e.g. those with previous episodes of HSV epithelial keratitis or HSV stromal keratitis, and individuals with AIDS or who are immunosuppressed) (Category 1 recommendation)

• Those patients who should receive oral aciclovir to suppress recurrences of HSV stromal keratitis remain to be defined but may include those with previous episodes of HSV epithelial keratitis or HSV stromal keratitis, and individuals with AIDS or who are immunosuppressed (Research need recommendation)

Oral aciclovir for the prophylaxis of HSV stromal keratitis in children

• Oral aciclovir (10–20 mg/kg/day) is recommended for prophylaxis of HSV stromal keratitis in children and must be used if topical steroids are employed to control inflammation (Category 2 recommendation)

Optimal duration of prophylactic antiviral therapy for HSV stromal keratitis

• The optimal duration of therapy and dose of aciclovir for prevention of recurrences of HSV stromal keratitis require further investigation (Research need recommendation)

Treatment of HSV Iritis

• Oral aciclovir may have an adjunctive role in the treatment of HSV iritis and should be examined further in a randomized clinical trial (Research need recommendation)

Antiviral prophylaxis following excimer laser surgery of the cornea

• The effect of antiviral prophylaxis on ocular HSV disease recurrence rates should be investigated in a clinical trial (Research need recommendation)

Use of Corticosteroids in Ocular HSV Disease

• Steroid therapy should be used sparingly in cases of extensive stromal disease or uveal inflammation (Category 3 recommendation)

• Topical corticosteroid therapy should not be used in the treatment of ocular HSV disease unless prescribed by an ophthalmologist (Category 3 recommendation)

• Antiviral therapy should be used in conjunction with steroids because of the increased risk of ocular HSV disease (Category 1 recommendation)

Vaccination for Ocular HSV Disease
Issues for vaccination

• Further animal studies are required to identify a candidate vaccine for ocular HSV disease (Research need recommendation).