Herpes simplex virus
Genital herpes: There are three antiviral medications that the U.S. Food and Drug Administration (FDA) has approved for the treatment of genital herpes. Approved antiviral drugs include acyclovir (Zovirax®), valacyclovir (Valtrex®), and famciclovir (Famvir®). Antiviral medication is commonly prescribed for patients having a first episode of genital herpes, but they can be used for recurrent episodes as well. There are two kinds of treatment regimens: episodic therapy and suppressive therapy. With episodic therapy, the patient begins taking the medication at the first sign of recurrence. The medication is then taken for several days to hasten the recovery or healing or to prevent a full outbreak from fully occurring. All three of the antiviral treatments mentioned above have been proven to help shorten the amount of time that a person may experience symptoms of herpes. However, results may vary from person to person. Side effects of antiviral medicines include
stomach upset, loss of appetite, nausea, vomiting, diarrhea, headache, dizziness, and/or weakness.
Suppressive therapy is used in individuals with genital herpes who want to eliminate (suppress) outbreaks altogether. Suppressive therapy is usually given to patients who have six or more recurrences per year. For these individuals, studies have reported that suppressive therapy may reduce the number of outbreaks by at least 75% while the medication is being taken. Also, for some, taking an antiviral on a daily basis can prevent outbreaks altogether. Suppressive therapy may completely prevent outbreaks in some patients. Side effects include nausea and vomiting. Suppressive therapy may need to be taken life-long.
Medications that are swallowed to treat oral herpes include the antiviral medications acyclovir (Zovirax®), valacyclovir (Valtrex®), and famciclovir (Famvir®). There are two topical antiviral medications prescribed for the treatment of oral herpes-simplex virus (HSV)- topical acyclovir ointment (Zovirax®) and topical penciclovir cream (Denavir®). Both of these drugs work to speed up the healing process and reduce the viral activity. These drugs are put directly on the lesions themselves, but can also be used at the onset of prodrome (early symptoms of itching and burning lasting up to one to two days).
Other topical treatments for oral herpes are available over-the-counter (OTC), but are not antiviral compounds like acyclovir and penciclovir. Some also contain anesthetic ingredients (such as lidocaine or benzocaine) that numb the area and induce temporary relief from the discomfort of an outbreak. Unfortunately, some OTC treatments may actually delay the healing time of symptoms because they can further irritate the area with repeated applications. There is only one U.S. Food and Drug Administration (FDA)-approved cream, docosanol (Abreva®), the only OTC drug that has been clinically proven to help speed the healing process.
Infected individuals can also prevent recurring outbreaks by avoiding some of the known causes. During an outbreak, symptomatic relief may be obtained by keeping the area clean and dry, or by taking pain relievers (such as aspirin, acetaminophen, or ibuprofen). Some patients with genital herpes find relief by taking a bath where a person simply sits in a tub with warm water up to the hips).
Varicella-zoster virus (chickenpox)
Pain medications: Treatment for chickenpox includes pain medicines such as acetaminophen (Tylenol®) or ibuprofen (Motrin®, Advil®). Do not give children less than 18 years of age aspirin, as a dangerous condition called Reye's syndrome can develop.
Soothing baths: Frequent baths are particularly helpful in relieving itching, especially when used with preparations of finely ground (colloidal) oatmeal. Commercial preparations of oatmeal, such as Aveeno®, are available in drugstores, or one can be made at home by grinding or blending dry oatmeal into a fine powder. Use about two cups per bath. The oatmeal will not dissolve, and the water will have a scum. One-half to one cup of baking soda in a bath may also be helpful.
: Calamine® lotion and similar over-the-counter preparations can be applied to soothe the skin and help dry out blisters and soothe the skin.
Antihistamines: For severe itching, a type of over the counter medication called antihistamine diphenhydramine (Benadryl®) is useful; it also helps children sleep.
Antiviral drugs: Acyclovir is an antiviral drug that may be used in adult varicella-zoster patients or those of any age with a high risk for complications and severe forms of chickenpox. The drug may also benefit smokers with chickenpox, who are at higher than normal risk for pneumonia. Some experts recommend its use for children who catch chickenpox from other family members because such patients are at risk for more serious cases. To be effective, oral acyclovir must be taken within 24 hours of the first signs of the rash. Early intravenous (IV) administration of acyclovir is also treatment for chickenpox pneumonia. Foscavir (Foscarnet®) is an injectable antiviral agent commonly used in treating cytomegalovirus (an infection caused by herpesvirus type 5). It is used in cases of varicella-zoster strains that have become resistant to acyclovir (Zovirax®) and similar drugs. Administered intravenously (into the veins), the drug can have toxic effects, such as kidney damage (which is reversible) and seizures. Fever, nausea, and vomiting are common side effects. It can also cause ulcers on the genitals organs. As with other drugs, it does not cure shingles. Antiviral drugs require a prescription.
Varicella-zoster virus (shingles)
The treatment goals for an acute (immediate) attack of shingles (herpes zoster) include reduce pain, reduce discomfort, hasten healing of blisters, and prevent the disease from spreading. Over-the-counter remedies are often effective in reducing the pain of an attack.
Antiviral drugs: Antiviral agents (acyclovir or Zovirax®), corticosteroids (prednisone or Delatasone®) are sometimes given to patients with severe symptoms, particularly if they are older and at risk for postherpes neuralgia.
Antihistamines: In general, to prevent or reduce itching, home treatments are similar to those used for chickenpox. Patients can try antihistamines, particularly diphenhydramine (Benadryl®, either orally or topically), oatmeal baths, and calamine lotion.
Oral corticosteroids: Drugs called oral corticosteroids, including methylprednisolone (Medrol®) or prednisone (Deltasone®), are used for inflammation associated with shingles. They have some benefit for reducing pain and accelerating healing in acute attacks of shingles when used with acyclovir (Zovirax®). However, they are not recommended without acyclovir. They also may be helpful for improving symptoms of Bell's palsy and Ramsay Hunt syndrome. Corticosteroids do not appear to prevent a further attack or reduce the risk for post herpetic neuralgia (PHN). Side effects of corticosteroids, including weight gain and lowered immunity, can be severe and oral steroids should be taken at as low a dose and for as short a time as possible.
Epidural blocks: Epidural blocks are injections of local anesthetics, pain medications, or steroids outside the tough membrane surrounding the spinal cord (the dura matter). The injected substances block the nerves and offer relief from acute herpes zoster pain for some people. Some studies, but not all, have indicated that if they are given early enough (within two months), they may prevent nerve damage that leads to postherpetic neuralgia. Combinations of anesthetics with steroids in the epidural blockade may be particularly beneficial. This procedure is invasive, however, and is not widely used.
Over-the-counter (OTC) pain relievers: For an acute (immediate) shingles attack, individuals may take over-the-counter (OTC) pain relievers, including acetaminophen (Tylenol®) or ibuprofen (Motrin®, Advil®). Children should take acetaminophen, not aspirin. Adults may take aspirin. Such remedies, however, are not very effective for postherpetic neuralgia.
Post herpetic neuralgia (PHN)
Postherpetic neuralgia (PHN) is difficult to treat. Once PHN develops, a multidisciplinary approach that involves a pain specialist, psychiatrist, primary care physician, and other healthcare professionals may provide the best means to relieve the pain and distress associated with this condition.
Anesthetic patches: Topical (on the skin) preparations, including a skin patch containing the anesthetic drug lidocaine (Lidoderm®), are generally used. They are effective in many people without producing any known severe side effects. The patch appears to reduce pain and improve quality of life for many patients. One to four patches can be applied over the course of 24 hours. Another patch (EMLA®) contains both the anesthetic drugs lidocaine and prilocaine. These patches are expensive and require a prescription. The most common side effects are skin redness or rash.
Topical creams: Capsaicin (Zostrix®) is prepared from the active ingredient in hot chili peppers. An ointment form has been approved for postherpetic neuralgia and is available over-the-counter (OTC). Its benefits are limited, however, and it is uncertain whether they are meaningful for most patients. A new patch form that uses a higher than standard dose may be more effective than current options. In one study, it reduced pain by 33% in nearly half of patients. Capsaicin should not be used until the blisters have completely dried out and are falling off the skin. Capsaicin ointment should be handled using a glove, and applied to affected areas three or four times daily. The patient will usually experience a burning sensation when the drug is first applied, but this sensation diminishes with use. It may take up to six weeks for the patient to experience its full effect, however, and about a third cannot tolerate the burning sensation. Many find no benefit.
Topical aspirin, known chemically as triethanolamine salicylate (Aspercreme®), may bring relief. Also, menthol-containing creams such as Ben Gay® and Flexall 454® may be helpful.
Oral medicines: Low-dose tricyclic antidepressant (TCAs), preferably nortriptyline (Pamelor®, Aventyl®), is also used. Side effects include drowsiness, fatigue (tiredness), dry mouth, and constipation. If that does not work, gabapentin (Neurontin®), an anti-seizure drug, can be used. Doctors usually start with a low dose and slowly increase the amount given until relief or severe side effects occur. Side effects include drowsiness and nausea or vomiting. Also, a type of painkilling drugs known as opiates, including oxycodone (Oxycontin®) or hydrocodone (Vicodin®, Lortab®), may be used. These drugs cause drowsiness and may cause physical dependence, even in short term use (two weeks or less).
Investigative agents: Cannabinoids are compounds in marijuana (cannabis) that may have properties that protect nerve cells. They are being studied for a number of nerve-disorders, including chronic nerve-related pain. In one study, they were effective in reducing pain and had no major side effects.
Mexiletine (Mexitil®) is a calcium channel blocking agent that alters nerve impulse transmission. It is normally used for heart rhythm disorders but is being used in some cases for PHN in patients who do not respond to standard agents. The agent can have adverse effects, including serious allergic reactions, nausea, vomiting, flushing, and arrhythmias (irregular heart beat).
Psychological approaches: A number of relaxation and stress-reduction techniques are helpful in managing chronic pain. They include meditation, deep breathing exercises, biofeedback, and muscle relaxation. Such techniques may apply to those with severe pain from acute infection and from persistent long-term postherpetic neuralgia. Cognitive behavioral therapy is showing benefit in enhancing patients' beliefs in their own abilities for dealing with pain. Using specific tasks and self-observation, patients gradually shift their fixed ideas that they are helpless against the pain that dominates their lives to the perception that it is only one negative and, to a degree, a manageable experience among many positive ones.
Good scientific evidence
Aloe: The transparent gel from the pulp of the meaty leaves of aloe (Aloe vera) has been used topically (on the skin) for thousands of years to treat wounds, skin infections, burns, and numerous other dermatologic conditions. Limited evidence suggests that A. vera in a cream preparation is an effective treatment for genital herpes in men. Additional research is warranted in this area.
Guided imagery: Therapeutic guided imagery may be used to help patients relax and focus on images associated with personal issues they are confronting. Experienced guided imagery practitioners may use an interactive, objective guiding style to encourage patients to find solutions to problems by exploring their existing inner resources. Although not clinically proven to work in herpes infections, guided imagery does seem to help lower pain in individuals in several clinical studies.
Lemon balm: Several clinical studies have reported that a topical preparation of lemon balm (Melissa officinalis) heals sores associated with oral herpes (herpes simplex type 1). More studies are needed in this area.
Lysine: Lysine is an amino acid that has been reported in several clinical studies to decrease the recurrence of herpes labialis (oral herpes, type 1). However, this use remains controversial and more scientific studies should be performed.
Therapeutic touch:Therapeutic touch may reduce pain associated with many conditions including herpes viruses, although no clinical studies have been performed in this area. However, most studies of therapeutic touch have not been well designed and therapeutic touch has not been clearly compared to common pain treatments such as pain-relieving drugs. Further research is needed before a firm conclusion can be drawn.
Zinc: Proper nutrition, including vitamins and minerals, has been reported to help in decreasing recurrent herpes infections. Lesser quality studies have been conducted to assess the effects of zinc (topical or taken by mouth) in herpes type 1 or type 2. A small study found that oral zinc sulphate appeared to reduce both the number of episodes and the time to recovery of herpes labialis. Several of these studies used combination treatments or permitted the continued use of other medications, so the exact role of zinc in those studies is unclear. However, the positive results obtained in most trials suggest that zinc may represent a safe and effective alternative or adjunct treatment for herpes type 1 and 2, and should encourage further research into the topic using well-designed studies.
Unclear or conflicting scientific evidence
Acupuncture: Several clinical studies have reported that acupuncture therapy is effective in reducing the pain associated with postherpetic neuralgia (PHN). More studies need to be performed before a firm conclusion can be drawn.
Chlorophyll: Oral consumption of chlorophyll liquid was reported in one clinical study to be effective in both herpes simplex and varicella-zoster infections. More clinical research is needed.
Dimethylsulfoxide (DMSO): Topical use of dimethylsulfoxide (DMSO) has been reported effective in the treatment of herpes zoster (shingles). One study reported that benefits may be more effective when DMSO is combined with the drug idoxuridine. Further research is necessary.
Honey: Honey is a sweet, viscid fluid produced by honeybees (Apis melliflera) from the nectar of flowers. It has been used for thousands of years as a healing agent. One small controlled trial found topical honey effective in treating labial but not genital herpes. More research is needed in this area to draw a conclusion. Honey should not be used in diabetic individuals.
Hypnosis: Hypnosis is associated with a deep state of relaxation. A small study showed potential benefit of a hypnotherapeutic treatment program for patients suffering from recurrent orofacial herpes infections. Further research is needed to confirm these results.
Licorice: Licorice (Glycyrrhiza glabra) has been found in laboratory studies to hinder the spread and infection of herpes simplex virus. Clinical studies need to be performed. Licorice may increase blood pressure in sensitive individuals.
Peppermint oil: The essential oil from peppermint (Mentha piperita) has been reported effective in decreasing recurrent herpes infection. One case report found that topical peppermint oil was effecting in reducing the pain of postherpetic neuralgia. More clinical studies are needed. Peppermint oil may burn the skin if undiluted.
Propolis: Propolis is a natural flavonoid-rich resin created by bees, used in the construction of hives. Propolis is produced from the buds of conifer and poplar tress, in combination with beeswax and other bee secretions. A limited number of laboratorystudies have demonstrated effectiveness of propolis and its constituents against herpes simplex virus types 1 and 2. Preliminary results from human trials suggest some degree of efficacy of topical propolis for resolving the lesions associated with genital herpes virus infections. More clinical research is needed.
Reishi: Reishi mushroom (Ganoderma lucidum) has been reported to improve immune system function in humans. Reishi extract was effective in decreasing postherpetic pain in one case series. However, there is insufficient data to make any conclusion.
Rhubarb: One double-blind, controlled trial indicates that topically applied rhubarb-sage extract cream may reduce the symptoms of herpes. It was compared to acyclovir (Zovirax®) cream and was equally effective in relieving the symptoms. More high quality studies using rhubarb as a monotherapy are needed to discern rhubarb's effect on herpes symptoms.
Tai chi: Tai chi is a system of movements and positions believed to have developed in 12th Century China. Tai chi techniques aim to address the body and mind as an interconnected system, and are traditionally believed to have mental and physical health benefits to improve posture, balance, flexibility, and strength. A small trial showed that treatment with tai chi might increase immunity to the virus that causes shingles. This may suggest the use of tai chi in the prevention of chickenpox and shingles, but further well-designed large studies should be performed. Tai chi can also help with physical fitness, which is important with individuals with weakened immune systems.
Tea tree oil: Tea tree oil, from the Melaleuca alternifolia tree, has been proposed as a potential topical therapy for genital herpes simplex virus infections based on in vitro findings of antiviral activity. However, at this time there is insufficient human evidence to recommend either for or against this use of tea tree oil. Tea tree oil should not be taken internally, although vaginal and rectal use is recommended by some healthcare providers. Apply tea tree oil with a cotton ball. If sensitivity develops, such as rash or irritation, diluting the oil with water may help. If the rash or irritation continues, discontinue use.
TENS: Transcutaneous electrical nerve stimulation (TENS) is a non-invasive technique in which a low-voltage electrical current is delivered through wires from a small power unit to electrodes located on the skin or using acupuncture-like needles. TENS helps stimulate the chi or energy of the body. TENS has been effectively used in treating pain associated with post-herpetic neuralgia in several clinical studies. However, more studies are needed.
Historical or theoretical uses lacking sufficient evidence
Arabinoxylan: Arabinoxylan is produced from Hyphomycetes mycelia mushroom extract. Arabinoxylan has been used traditionally for herpes zoster infection and to treat postherpetic neuralgia. Arabinoxylan increases immune function and may help the body fight off infection. Clinical studies are needed to support these uses.
Astragalus: Astragalus (Astragalus membranaceous) has been used for centuries in traditional Chinese medicine (TCM) as a restorative tonic for the aged and debilitated, according to secondary sources. Astragalus is used traditionally for immune support and may be used for viral infections such as herpes. Several laboratory studies report that astragalus is effective against the herpes simplex type 1 (HSV-1) virus. Clinical studies need to be performed to support these findings.
Other integrative therapies that may have benefit in the treatment of herpes infections or the prevention of herpes recurrence includebitter melon (Momordica charantia), bromelain (from Ananus comosus), topical calendula (Calendula officinalis), cat's claw (Uncaria tomentosa), topical clove (Eugenia aromatica) and clove oil (eugenol), topical eucalyptus oil (Eucalyptus globulus), ginseng (Panax ginseng), goldenseal (Hydrastis canadensis), gotu kola (Centella asiatica), olive leaf (Olea europaea), raspberry (Rubus idaeus), reflexology, and shiitake (Lentinus edodes).
Herpes simplex virus type 1 (HSV-1, herpes labialis, oral herpes)
Taking steps to guard against the development of cold sores, to prevent spreading them to other parts of the body, or to avoid passing them along to another person is important when dealing with oral herpes.
Contact with infected individuals: The virus can spread easily as long as there are moist secretions from blisters. In individuals with depressed immune systems, the virus can be spread even after the skin appears to be healed. Also, not kissing others on the mouth if a herpes viral infection is present is important.
Sharing common items: Utensils, towels, water glasses, and other commonly used items can spread the virus when blisters are present.
Clean hands: Washing the hands carefully before touching another person when a cold sore is present is very important. The eyes and genital area may be particularly susceptible to spread of the virus.
Triggers: Avoiding or preventing conditions that stress the body, such as poor diet, not getting enough sleep, or staying in the sun for long periods of time without applying sun-block is very important in preventing oral herpes outbreaks.
Herpes simplex virus type 2 (HSV-2, genital herpes)
Measures for preventing genital herpes are the same as those for preventing other sexually transmitted diseases (STDs). HSV-2 is highly contagious while lesions are present. The best way to prevent infection is to abstain from sexual activity or to limit sexual contact to only one person who is infection-free. Individuals should use, or have their partner use, a latex condom during each sexual contact, limit the number of sex partners, avoid any contact with a partner who has sores until the sores are completely healed, or use a male or female condom during anal, oral, or vaginal sex (however, transmission can still occur if the condom does not cover the sores), avoid having sex just before or during an outbreak since the risk for transmission is highest at that time, and ask the sexual partner if they have ever had a herpes outbreak or been exposed to the herpes virus. Also, getting tested for herpes-simplex viruses is important if the individual is sexually active outside of a monogamous relationship.
If an individual is pregnant, it is important to tell the doctor that HSV is present. If the individual has had unprotected sex and is unsure, testing for HSV is recommended by healthcare professionals. Watch for signs and symptoms of HSV during pregnancy. A doctor may recommend that the individual start taking herpes antiviral medications when they are about 36 weeks pregnant to try to prevent an outbreak from occurring around the time of delivery. If the individual is having an outbreak when they go into labor, the doctor will probably suggest a Caesarean section to reduce the risk of passing the virus to the baby.
A vaccine in clinical trials is being tested in women who have not been infected with herpes simplex virus (HSV). The vaccine is Herpevac® and may become available for prevention of genital and oral herpes infections.
Human herpesvirus type 3 (varicella-zoster virus, chickenpox)
Varivax®: A vaccine for varicella-zoster infections is now used to prevent chickenpox. Varivax®, a live virus vaccine, produces persistent immunity against chickenpox. Data show that the vaccine can prevent chickenpox or reduce the severity of the illness even if it is used within three days, and possibly up to five days, after exposure to the infection. The vaccine against chickenpox is now recommended in the United States for all children between the ages of 18 months and adolescence who have not yet had chickenpox. Children are given one dose of the vaccine. Two doses one to two months apart are given to people over 13 years of age. To date, more than 75% of children have been vaccinated.
Some experts suggest that every healthy adult without a known history of chickenpox be vaccinated. Adults without such a history of infection by varicella-zoster should strongly consider vaccination if they are adults who are at high risk of exposure or transmission (hospital or day care workers, parents of young children), individuals who live or work in environments in which viral transmission is likely, individuals who are in contact with people who have compromised immune systems, non-pregnant women of childbearing age, adolescents and adults living in households with children, and international travelers.
Women who are trying to become pregnant should postpone conception until three months after the vaccine.
Side effects of Varivax® include discomfort at the injection site. About 20% of vaccine recipients have pain, swelling, or redness at the injection site. Only about five percent of adverse reactions are serious. Adverse events may include seizures, pneumonia, anaphylactic reaction (a life-threatening allergic reaction), encephalitis (inflammation of the brain), Stevens-Johnsons syndrome, neuropathy (nerve damage), herpes zoster, and blood abnormalities. The vaccine may also produce a mild rash within about a month of the vaccination that has been known to transmit chickenpox to others. Individuals who have recently been vaccinated should avoid close contact with anyone who might be susceptible to severe complications from chickenpox until the risk for a rash has passed. Months or even years after the vaccination, some people develop a mild infection termed modified varicella-like syndrome (MVLS). The condition appears to be less contagious and have fewer complications than naturally acquired chickenpox.
There is currently intense debate over the long-term protection of the vaccine. Studies have reported that more than 15% of vaccinated children still develop chickenpox (called breakthrough infections). The long-term protective effect for adults is even less clear. Between 1979 and 1999, it was reported that although nine percent developed chickenpox months to years after their last vaccination, in all cases, infection was mild with none of the serious complications of adult chickenpox. A 2003 study on booster shots in older adults suggests that revaccination with the live virus is safe and effective.
Varicella-zoster immune globulin (VZIG): Varicella-zoster immune globulin (VZIG) is a substance that triggers an immune response against the varicella-zoster virus (VZV). It is used to protect high-risk patients who are exposed to chickenpox or those who cannot receive a vaccination of the live virus. Such groups include pregnant women with no history of chickenpox, newborns under four weeks who are exposed to chickenpox or shingles, premature infants, children with weakened immune systems, adults with no immunity to VZV, and recipients of bone-marrow transplants (even if they have had chickenpox). VZIG should be given within 96 hours and no later than ten days after exposure to someone with chickenpox.
Human herpesvirus type 3 (varicella-zoster virus, shingles)
Zostavax®: Zostavax® is a live vaccine made from the herpes zoster virus that causes shingles. Zostavax® has been reported to reduce the incidence of herpes zoster by 51.3% in adults aged 60 and older who received the vaccine. The vaccine also reduced by 66.5% the number of cases of postherpetic neuralgia and reduced the severity and duration of pain and discomfort associated with shingles by 61.1%. Zostovax was approved by the U. S. Food and Drug Administration (FDA) in May 2006. The FDA recommended it only for adults aged 60 and older who meet requirements. These requirements include not having a life-threatening allergy to gelatin nor a life-threatening allergy to the antibiotic neomycin or other component of the herpes zoster vaccine. Individuals should not have a weakened immune system due to HIV/AIDS human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS), or any other disease. Patients should also not be on other disease medications, such as steroids, radiation, or chemotherapy, which affect the immune system. There should be no history of cancer of the bone marrow or lymphatic system, such as leukemia or lymphoma, and also no active or untreated tuberculosis. Side effects include headache, itching, and tenderness or redness at site of injection.
Zostavax® is not a substitute for Varivax® in children.