How to prevent the spread of HSV-1 virus to new outbreak sites?

Question

Hello doctor,

I am a 46-year-old male. I have recurring HSV-1 around the base (and inside) the nose. I have an outbreak now and my last outbreak was about 52 days ago. In childhood, I began with blisters on the lips; in the past five to 10 years, it seems it has migrated to the nose. Also, in the past, I could take Acyclovir or Valacyclovir successfully for treatment. And for a period of some years, I was able to take 500 mg Valacyclovir daily as a prophylaxis. But now those drugs (and also Famciclovir, which I have tried recently) each cause dose-dependent unpleasant side effects of CNS stimulation and muscle tension. So, my upcoming question is regarding treatment strategy and options. My inclination when outbreaks recur is to take Famciclovir at a low dose (250 mg initially and 125 mg every 12 hours for three days). It is not clear how much this may actually help, but it is what I feel comfortable presently doing and the side effects are at least tolerable at this dose. I would not want to take it daily at this dose though. There tends to be a crash after finishing it from the drop/lapse in stimulation.

With this background, on to my questions: Does the frequency of outbreaks increase the likelihood of spreading the virus to new locations? Again, I am seeing a frequency of about every two months. I am particularly concerned about ocular herpes. What I am driving at is, can I feel safe in avoiding taking a daily, preventive dosing of an antiviral? And when I get an outbreak, do I need to treat it at a high dose of antiviral (or treat it at all, really) to prevent the spread to new outbreak sites (such as to the eye, or even other parts of the face)? I worry that I need to try to endure the side effects of the antivirals in order to prevent the virus from spreading to new locations (again, such as the eye). Perhaps you can help assuage me of this fear. My current medications are Synthroid 75 mcg daily, Lansoprazole 30 mg daily AM, Omeprazole 40 mg daily PM and Prozac 35 mg daily.

Answer 1

Hello,

Welcome to icliniq.com.

I went through your post. I can understand the pain and frustration that a person goes through while getting a recurring infection and is on treatment for prolonged periods. Our options for herpes is limited. The guidelines say that for recurrent HSV (herpes simplex virus) infection whether HSV-1 or 2, start Acyclovir 400 mg twice daily or Valacyclovir 500 mg twice daily for a period of one year and reassess after one year.

The symptoms of CNS (central nervous system) stimulation can be treated with SSRI (selective serotonin reuptake inhibitor) like Sertraline 50 mg and increased after two weeks to 100 mg. That should help the side effects.

The reactivation is caused by some precipitating factors which include fever, pneumonia, stress, exhaustion, etc.

The recurrent episodes are milder than primary episodes. If a person has a severe recurrent episode, then suppressive therapy is given. If symptoms are mild and the person is immunocompetent, then the treatment of acute episodes with the treating dose of antivirals is given (Acyclovir 400 mg five times) and in between no treatment is needed.

Generally, recurrent herpes involves the same site and rarely may change it to involve other sites, especially in HIV (human immunodeficiency virus) patients were it would cause systemic infection and meningitis and other organ involvement.

Your question is do you need treatment at the time of acute infection. I would say, yes take full treatment, for example, Acyclovir 500 mg five times a day for five days. It will decrease the severity as well as the duration of the symptoms at the time of acute infection.

If you think your recurrence is only a few per year and not severe, then you may not need to take continuous preventive therapy. You can only take at the time of activation.

Regards.

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Answer 2

Hello,

Welcome back to icliniq.com.

You do not need to apologize. You have not done anything wrong. So, let us come to the point.

The CNS side effects of the antivirals Acyclovir, Famciclovir and Valacyclovir are seen in 1 to 5 % of the patients only. Unfortunately, you are one among them, the nervous system side effects are hallucinations, aggression, depression, and rarely coma and are generally seen in people with abnormal kidney functions, especially hallucinations and coma. The SSRIs are given to control aggression or depression part.

Famciclovir is given in immunocompromised patients because it is a very good drug, preferably more effective than the other two. So, it is used in HIV patients which means there is no problem even if you take Famciclovir.

You are saying that herpes has spread from the lip to the nose in 15 years. Let me tell you something about it. The trigeminal nerve has three divisions - mandibular, maxillary and ophthalmic. But, the virus is present in the trigeminal ganglion which is a common site and it can spread down to involve any division once reactivated by a precipitating factor. Fortunately, it commonly involves maxillary and mandibular part and rarely ophthalmic division. That means it is a matter of chance.

However, new cases of herpes keratitis have been seen in people with direct HSV-1 contact with the virus.

Regarding the decision to start the antivirals or not, let me tell you, HSV keratitis is the most common cause of blindness in the western world. However, it is also treatable if detected early. So, if you develop any symptoms like pain, photophobia, redness of the eye, immediately start any of the three antivirals as a treatment dose. For example, Acyclovir 400 five times a day and consult an ophthalmologist and avoid preventive doses to prevent recurrence.

The benefits of not taking meds outweigh taking but, remember, as soon as you feel eye symptoms or involvement of ophthalmic division consult an ophthalmologist immediately.

Regards.

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Answer 3

Hello,

Welcome back to icliniq.com.

Your GFR (glomerular filtration rate) I believe should be more than 80 and I expect your serum creatinine less than 1.1 which is normal at this age. So, the possibility of severe CNS side effects is very rare, if at all, in people with normal kidney functions and I never said you are at high risk for coma. I said these are the CNS related side effects of these antivirals and it should not prevent you from taking these meds. However, monitoring kidney functions are important because these meds can also cause nephrotoxicity. The coma is reversible with dialysis. So, it is transient because once the drug is out of the body the person will regain consciousness. It occurs in people with abnormal kidney functions because 90 % of the drug is removed by kidneys.

Direct contact keratitis occurs in people who are not infected with HSV and yes autoinoculation from a ruptured blister although rare has been seen to cause keratitis especially in people who are immunocompromised.

HSV is the most common cause of corneal blindness (I have missed the word corneal in the previous post) and the most common source of infectious blindness in the western world.

I would also suggest you stop one PPI (proton pump inhibitor) because you are taking two - Lansoprazole and Omeprazole. It has been seen to decrease the immune status and one PPI is enough to control the acid peptic disease. Two doses are recommended only if the person has an active GI (gastrointestinal) bleed or is on prolonged NSAID (non-steroidal anti-inflammatory drug) therapy that too on high doses.

I hope I was helpful. Regards.

For more information consult an internal medicine physician online --> https://icliniq.com./ask-a-doctor-online/internal-medicine-physician