Treatment

Treatment of primary HSV-1 infection is well established; however, treatment of muco-cutaneous, recurrent HSV-1 infection is less well defined, and treatment of polyganglionitis is controversial (8). Symptomatic and asymptomatic recurrent disease accompanied by

viral shedding is self-limited; therefore, therapy is designed to reduce severity, duration, and frequency of symptoms. In general, early treatment achieves the best therapeutic response.

Acyclovir binds viral DNA and ends viral replication by acting as a chain terminator. Although acyclovir is safe and extremely well tolerated, its oral availability is only about 15%, and its half-life is only about 2.5 hours. The drug penetrates most body tissues, including the brain, and crosses the placenta. Intravenous administration of acyclovir increases its concentration by tenfold. Because the drug is excreted through the kidneys, adjustment must be made for patients with renal impairment.

Because of the poor bioavailability and short half-life of acyclovir, oral treatment regimens of the drug require that it be administered five times per day. Valacyclovir and famciclovir are newer drugs with longer half-lives and better intestinal absorption. Valacyclovir, the prodrug of acyclovir, produces higher peak levels and has 55% bioavailability. Famciclovir, the prodrug of penciclovir, has a half-life 10 times longer than acyclovir and 77% bioavailability. Contraindications include hypersensitivity. Concurrent administration of probenecid or cimetidine may increase toxicity of either valacyclovir or famciclovir.

To treat the primary infection, patients receive a 7- to 10-day regimen of 200 mg acyclovir orally five times daily (or 400 mg orally three times daily) (14); valacyclovir 1000 mg orally twice daily (15); or famciclovir 250 mg orally three times daily (16). Patients who are immunocompromised or have disseminated disease should receive acyclovir intravenously every eight hours for 5 to 10 days with appropriate adjustment made for the patient's weight and the severity of disease.

Recurrent mucocutaneous disease is best treated in the prodromal stage or within 48 hours after formation of vesicles. Treatment should consist of 200 mg acyclovir given orally five times per day or 500 mg valacyclovir given orally twice per day or 125 mg famciclovir given orally three times per day for five days. In patients with intact immune systems, adding a regimen of steroid drugs lessens the severity of disease and dries the vesicles but does not shorten the course of the disease. Use of steroid agents in patients with HIV can cause fulminant oral candidiasis.

Patients with HSV-1 ocular infection should receive a double dose of acyclovir. Topical steroid agents are contraindicated for these patients, who should receive referral to an ophthalmologist.

For long-term suppression of recurrent episodes, patients should receive 100 mg acyclovir twice daily (14), 500 mg valacyclovir daily (15), or a 125- to 250-mg dose of famciclovir twice daily (16).

Unfortunately, treatment of neurologic symptoms associated with polyganglionitis is determined on the basis of each treating physician's own philosophy. Because the disease is both inflammatory and a virally induced immune complex, use of steroid drugs is the most effective method of reducing the severity and duration of sensory symptoms (17). Methylprednisolone can reduce symptoms of acute vestibular vertigo (neuritis, neuronitis, and labyrinthitis) within hours after treatment (18). For affected patients who have associated nausea and vomiting, intravenous administration of a single 100-mg bolus of methylprednisolone relieves the vertigo within hours. Adults receive follow-up treatment consisting of 40 to 60 mg generic prednisone given orally for five days. For adults with unilateral parietal-occipital headache and evidence of other cranial nerve involvement, 40 mg prednisone given twice daily for three to four days has proved highly effective.

Now that Bell' s palsy has been recognized as a form of polyganglionitis, treatment with steroid agents and acyclovir has become an accepted form of therapy (19). As with any herpetic disease, the most effective treatment is given early, i.e., within three days after the onset of the palsy. Patients diagnosed with Bell's palsy should receive 500 mg valacyclovir twice daily, 250 mg famciclovir three times daily, or 200 mg acyclovir five times daily. For these patients, prednisone treatment begins with at a dosage of 60 mg twice daily and is then tapered downward in increments of 5 mg per dose for the next seven days. The role of surgical decompression remains controversial; this treatment should be undertaken only under strict guidelines (which are beyond the scope of this chapter).

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