A Nurse Practitioner's Guide to the Management of Herpes Simplex Virus-1 in Children

Janel M. Drugge, MSM, RN, PNP; Patricia Jackson Allen, MS, RN, PNP, FAAN

Disclosures

Dermatology Nursing. 2008;20(6):455-466. 

In This Article

Evidence-Based Treatment Approaches

Topical medication. Treatment for HSV-1 outbreaks varies according to the severity of the lesions, as well as the degree of need for comfort and support for the individual affected (see Table 1 ). The goals of HSV-1 treatment are to decrease pain and discomfort associated with the lesions, shorten the time of viral shedding, limit the duration and severity of outbreaks, and prevent further complications (Blevins, 2003; Ensor, 2005). Several antiviral topical medications are available to treat mild primary or recurrent outbreaks by increasing healing time and decreasing lesion severity and associated discomfort (Raborn & Grace, 2003). Acyclovir (ZoviraxAE), an acyclic purine nucleoside analogue, limits the replication and spread of the virus to other cells, but it cannot kill cells already infected with HSV-1 (Yeung-Yue et al., 2002). Acyclovir is available as a 5% ointment cream (Takemoto, Hodding, & Kraus, 2007) and can decrease viral shedding and shorten healing time by treating initial and recurrent HSV-1 infections (Blevins, 2003; Takemoto et al., 2007).

Penciclovir (DenavirAE), a prodrug of acyclovir, is available only in the topical form to treat mild recurrent HSV-1 outbreaks (Takemoto et al., 2007). Two large, double-blind, placebo-controlled clinical trials demonstrated that penciclovir 1% cream significantly reduced healing time and the duration of pain (Raborn, 1996; Raborn et al., 2002; Spruance et al., 1997). Due to its poor oral bioavailability, penciclovir is not available as an oral preparation (Woo & Challacombe, 2007; Yeung-Yue et al, 2002).

Docosanol (AbrevaAE), a behenyl alcohol, became the first over-the-counter (OTC) antiviral drug sold in the United States in 2000 (Woo & Challacombe, 2007). Docosanol is available as a 10% topical cream for the treatment of recurrent HSV-1 infections and should be applied during the prodromal phase of burning and tingling prior to the development of a lesion (Brady & Bernstein, 2004). Two randomized, placebo-controlled clinical trials showed that docosanol 10% topical cream helps reduce healing time by 1.6 to 4.6 days by significantly decreasing the healing time of the ulcer and crusting stage, as well as shortening the duration of the painful symptoms (Habbema, De Boulle, Roders, & Katz, 1996; Sacks et al., 2001).

Many OTC topical preparations can help decrease the discomfort caused by HSV-1 outbreaks. These topical anesthetic ointments and creams include AnbesolAE, BlistexAE, Campho-pheniqueAE, CarmexAE, OrabaseAE, and OrajelAE. Active ingredients in these topical preparations include benzocaine, lidocaine, tetracaine, benzyl alcohol, camphor, and phenol. These topical ointments do not heal HSV-1 lesions, but they help to alleviate some of the pain during the outbreak (Kleymann, 2003). The topical medication should be applied at the first sign of the prodrome period of tingling and burning, and thus, prior to lesion development.

Systemic medication. Systemic medication in the form of antivirals may be necessary in children experiencing three to five episodes of HSV-1 a year or in severe HSV-1 infections (Raborn & Grace, 2003). Early diagnosis and treatment is critical because HSV replicates quickly even before lesions have appeared. Antivirals must be started before damage to the epithelial has occurred (Woo & Challacombe, 2007). Acyclovir (ZoviraxAE) is available in suspension, tablet, and intravenous dosing forms for severe primary or recurrent outbreaks (Takemoto et al., 2007). Acyclovir requires frequent dosing of three times a day for 5 to 10 days due to its short half life of 1 hour (Takemoto et al., 2007). Systemic acyclovir has been shown to reduce healing and pain by 1 to 1.5 days, and reduce viral shedding (Woo & Challacombe, 2007).

Newer prodrug forms of acyclovir are now available in oral preparations that require less-frequent dosing schedules. Valacyclovir (ValtrexAE), a prodrug of acyclovir, has an oral bioavailability "three to five times higher than that of acyclovir, approaching levels comparable with intravenous acyclovir" (Yeung-Yue et al., 2002, p. 256). Two large randomized, placebo-controlled clinical trials concluded that valacyclovir significantly reduces the duration of HSV-1 infections, shortens the time of crusting, and reduces the duration of pain (Spruance et al., 2002, 2003). Valacyclovir is only available as an oral preparation (Takemoto et al., 2007).

Famciclovir (FamvirAE), an oral prodrug of penciclovir, also has a mechanism similar to acyclovir when metabolized and is only available as tablets to treat severe outbreaks (Brady & Bernstein, 2004; Simpson & Lyseng-Williamson, 2006; Takemoto et al., 2007). Famciclovir has been shown to shorten healing time and lessen the size of HSV lesions (Spruance et al., 1999, 2006). Single-dose or single-day dosing regimens have contributed to treatment compliance and overall satisfaction (Simpson & Lyseng-Williamson, 2006).

A few cases of acyclovir-resistant HSV-1 infections have been seen in immuncompromised persons (Yeung-Yue et al., 2002). Foscarnet (FoscavirAE), an analogue of pyrophosphate given intravenously, is FDA-approved for the treatment of HSV-1 infections resistant to acyclovir (Takemoto et al., 2007; Yeung-Yue et al., 2002). For severe HSV-1 infections that are resistant to both acyclovir and foscarnet, intravenous cidofovir (Vistide AE ), a monophosphate molecule that stops DNA chain elongation, is available (Bryant, Sasadeusz, Carapetis, Waters, & Curtis, 2001; Takemoto et al., 2007; Yeung-Yue et al., 2002). HSV-1 disease due to resistant strains is almost exclusively found in individuals who are immuncompromised (Brady & Bernstein, 2004).

Other oral medications can be used to help with the pain and discomfort of HSV-1 outbreaks. Acetaminophen or ibuprofen can be used to help with mild or moderate pain associated with lesions. Severe pain requires hospitalization and treatment with intravenous narcotics (Blevins, 2003).

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