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 it 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 weakness.
Suppressive therapy is used in individuals with genital herpes who want to suppress (eliminate) 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.
Over-the-counter (OTC) creams and ointments are usually not recommended for the treatment of genital herpes, as they may cause the outbreaks to last longer by inhibiting the healing process.
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 type 1 (HSV-1): 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 1-2 days).
Other over-the-counter (OTC) topical treatments for oral herpes are available, but they 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 symptom healing time due to further irritation at the infected area with repeated applications. Docosanol (Abreva®) is the only OTC cream to be approved by the U.S. Food and Drug Administration (FDA) 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 (simply sitting in a tub with warm water up to the hips).
Varicella-zoster virus (chicken pox)
Pain medications: Treatment for chicken pox 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 colloidal (finely ground) 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 chicken pox. The drug may also benefit smokers with chicken pox, who are at higher-than-normal risk for pneumonia. Some experts recommend its use for children who catch chicken pox 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; into the veins) administration of acyclovir is also a treatment for chicken pox 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, 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 genital 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 reducing pain, reducing discomfort, hastening the healing of blisters, and preventing the disease from spreading. Over-the-counter remedies are often effective in reducing the pain of an attack.
Antiviral drugs: Antiviral agents (acyclovir, valacyclovir, and famciclovir) 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 chicken pox. 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 postherpetic 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 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.
Postherpetic 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 over-the-counter (OTC) ointment form has been approved for postherpetic neuralgia and is available. 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 antidepressants (TCAs), preferably nortriptyline (Pamelor®, Aventyl®), are also used. Side effects include drowsiness, fatigue (tiredness), dry mouth, and constipation. If that does not work, gabapentin (Neurontin®), an antiseizure 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 cannabis (marijuana) 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 heartbeat).
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 to deal 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.
While antiviral drugs or vaccines are lacking for the treatment of EBV-induced mononucleosis, some doctors may prescribe a five-day course of steroids to treat the swelling of the throat and tonsils that often coincides with the infection.
Ganciclovir (Cytovene®) is an antiviral medication that is prescribed to individuals with weakened immune systems experiencing CMV retinitis (infection of the eye that can lead to blindness). In addition, ganciclovir may be prescribed to individuals with acquired immunodeficiency syndrome (AIDS) or to those who have received an organ transplant to prevent CMV infection.
Good scientific evidence
Aloe: Limited evidence suggests that aloe in a cream preparation is an effective treatment for genital herpes in men. Additional research is warranted in this area.
Caution is advised when taking aloe supplements, as adverse effects, including diarrhea and drug interactions, are possible. Aloe supplements should not be used if pregnant or breastfeeding, unless otherwise directed by a doctor. Do not use for more than three days without consulting a doctor.
Green tea: Polyphenon E® ointment, containing an extract of green tea, has been approved in the United States for treatment of genital warts caused by human papillomavirus. Although this shows promise, further research is needed before a stronger conclusion can be made.
Take care when using green tea with alcohol, antifungals, birth control pills, decongestants, and diuretics, and in patients with blood disorders, cardiovascular disorders, breast disease, an empty stomach, eye disorders, gastrointestinal disorders, impaired iron metabolism, iron deficiency, liver disorders, or psychiatric disorders. Use with caution in postmenopausal women, patients prone to headaches, and those at risk for prostate cancer or osteoporosis. Use with caution in patients using agents to treat eye disorders, agents that affect the gastrointestinal system, agents that affect hormone levels, agents that may damage the liver, or agents that affect the nervous system, as well as when using iron, painkillers, or other agents containing caffeine. Use of the green tea extract Polyphenon E® ointment may result in skin irritation or sun sensitivity. Avoid taking in excessively high amounts by mouth; during pregnancy and breastfeeding; or with known allergy or sensitivity to green tea, its constituents, caffeine, tannins, or members of the Theaceae family.
Lemon balm: Several clinical studies have reported that a topical preparation of lemon balm (Melissa officinalis) heals sores associated with oral herpes simplex virus infections (herpes simplex type 1). However, rigorous clinical data are lacking, even though preliminary clinical studies demonstrate promising effects. According to available research, lemon balm taken by mouth has been reported to be relatively well tolerated when taken for up to eight weeks. Evidence for topical administration of cream suggested minimal side effects from up to 10 days of application. Avoid if allergic or hypersensitive to lemon balm. Avoid with Graves' disease or thyroid hormone replacement therapy. Use cautiously in glaucoma, because lemon balm may increase eye pressure. Use caution when operating heavy machinery. Lemon balm preparations may contain trace amounts of lead. Avoid if pregnant or breastfeeding.
Para-aminobenzoic acid: Actipol® is a 0.007% para-aminobenzoic acid (PABA) solution for eye use that has been studied for the treatment of inflamed corneas caused by the herpes virus. The solution has been found to be effective in curing most patients. Further studies may provide additional useful information on the use of PABA for this condition.
Sun exposure has been shown to stimulate the reactivation of a herpes simplex virus infection on the lips, as well as in the mouth or gums. Limited research suggests that PABA in sunscreen may be effective in preventing recurrent herpes labialis. Further studies will provide additional useful information on the use of PABA for this condition.
PABA taken by mouth is generally well tolerated. Doses taken by mouth may need to be adjusted in patients with impaired kidney function. Pharmaceutical doses of PABA and its derivatives should only be taken under the supervision of a qualified healthcare provider. PABA given intravenously may increase the risk of bleeding. Caution is advised in patients with bleeding disorders or those taking drugs, herbs, or supplements that may increase the risk of bleeding. PABA may lower blood sugar levels. Caution is advised in patients with diabetes or hypoglycemia, and in those taking drugs, herbs, or supplements that affect blood sugar. Use with caution in patients with kidney disease and when taking by mouth in doses greater than eight grams daily. Discontinue if rash, nausea, or anorexia occur. Avoid taking at the same time as sulfonamide antibiotics, as it may reduce their effectiveness. Avoid giving by mouth to children, due to an increased risk of serious side effects. Avoid in pregnant or breastfeeding women, due to a lack of available scientific evidence. Avoid with known allergy or hypersensitivity to para-aminobenzoic acid (PABA) and its derivatives para-aminomethylbenzoic acid (PAMBA), butyl aminobenzoate (BAB), padimate O (octyl dimethyl PABA), potassium para-aminobenzoate (KPAB or POTABA®), N-benzoyl-L-tyrosyl PABA, Actipol®, or ursodeoxycholic acid-PABA.
Zinc: Low-quality studies have been conducted to assess the effects of zinc (topically or taken by mouth) on herpes simplex virus type 1 or type 2. 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 treatment for herpes simplex virus type 1 and type 2 and should encourage further research into the topic using well-designed studies.
Zinc is generally considered safe when taken at the recommended dosages. Use cautiously in patients with bleeding disorders, diabetes, or low blood sugar levels, or in patients taking agents for these conditions. Use cautiously in patients with high cholesterol or blood fats, a high risk of developing heart disease, various skin disorders, gastrointestinal disorders, liver disease, genitourinary conditions, blood disorders, neurological disorders, pulmonary or respiratory disorders, immune disorders, or kidney disease, or in patients taking antidepressants, potassium-sparing diuretics, antibiotics (particularly tetracyclines and quinolones), iron, penicillamine, thyroid hormones, or copper. Avoid in patients who are homozygous for hemochromatosis (a metabolic disorder involving the deposition of iron-containing pigments in the tissues and characterized by bronzing of the skin, diabetes, and weakness) or with a known allergy or hypersensitivity to zinc compounds. Avoid use of intranasal Zicam®.
Unclear or conflicting scientific evidence
Acupuncture: According to early research, acupuncture therapy may help treat herpes zoster and improve symptoms of pain associated with postherpetic neuralgia (PHN). However, more high-quality studies are needed before a conclusion can be made.
Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders or anticoagulants (drugs that increase the risk of bleeding), medical conditions of unknown origin, or neurological disorders. Avoid on areas that have received radiation therapy and during pregnancy. Use cautiously in those with pulmonary disease (like asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics, or those with history of seizures. Avoid electroacupuncture with arrhythmia (irregular heartbeat) or in patients with pacemakers.
Astragalus: Some studies suggest that astragalus may inhibit herpes viruses. Additional research is needed in this area.
Use cautiously in patients using immunosuppressant agents or those who have autoimmune disease. Use cautiously in patients with bleeding disorders or those taking agents that may increase the risk of bleeding. Use cautiously in patients with diabetes or low blood sugar, and in those taking agents that affect blood sugar. Use cautiously in patients with high blood pressure or those taking agents that affect blood pressure. Use cautiously with agents that increase urination, anesthetics, beta-blockers, colchicines, dopamine agonists, growth hormones, neuromuscular blockers, and stimulants. Astragalus is not suggested during pregnancy or breastfeeding. Avoid with known allergy or hypersensitivity to Astragalus membranaceus, its constituents, or other members of the Fabaceae family. In theory, patients with allergies to members of the Leguminosae (pea) family may react to astragalus. Cross-reactivity with quillaja bark (soapbark) has been reported. A positive skin reaction to Huangqi powder injection has been reported.
Chlorophyll: Oral consumption of chlorophyll liquid was reported in clinical research to be effective in both herpes simplex and varicella-zoster infections. More clinical research is needed.
Avoid if allergic or hypersensitive to chlorophyll or any of its metabolites. Use cautiously in those with photosensitivity, compromised liver function, diabetes, or gastrointestinal conditions or obstructions. Use cautiously in those taking immunosuppressant agents or antidiabetic agents. Avoid if pregnant or breastfeeding.
Dimethylsulfoxide (DMSO): DMSO may help treat herpes zoster. This treatment may work even better when used with the drug idoxuridine. Further research is necessary before a conclusion can be made.
Avoid if allergic or hypersensitive to DMSO. Use caution with urinary tract cancer or liver or kidney dysfunction. Avoid if pregnant or breastfeeding.
Echinacea: A small clinical trial assessing the potential benefit of oral echinacea for recurrent genital herpes found no effect. However, because research on the effect of echinacea for recurrent genital herpes is limited, conclusions cannot be made without further trials.
Use injectable preparations of echinacea cautiously. Its safety has not been established. Use tinctures cautiously with alcoholic patients or in patients taking agents processed by the liver or those that affect or damage the liver (including anabolic steroids, amiodarone, methotrexate, or ketoconazole), agents that affect the immune system, amoxicillin, anticancer agents, disulfiram or metronidazole, or kava. Use cautiously in patients with HIV/AIDS, collagen vascular diseases, multiple sclerosis, tuberculosis, some types of cancer, rheumatologic diseases (such as rheumatoid arthritis or lupus), hemochromatosis (an iron storage disease), or asthma; those at risk for allergic skin reactions; or those taking agents to treat any of these conditions. During pregnancy or breastfeeding, injection or infusion of echinacea is not recommended. Tinctures are not recommended due to their high alcohol content. Avoid in patients undergoing anesthesia (those put to sleep for surgery). Avoid with known allergy or sensitivity to echinacea, its constituents, or any members of the Asteraceae (Compositae) family (including ragweed, chrysanthemum, marigold, and daisy).
Honey: Preliminary research found honey effective in treating labial but not genital herpes. More research is needed in this area to draw a firm conclusion.
Avoid if allergic or hypersensitive to honey, pollen, celery or bees. Honey is generally considered safe in recommended doses. Avoid honey from the genus Rhododendron because it may cause a toxic reaction. Avoid in infants younger than 12 months of age. Use cautiously with antibiotics. Potentially harmful contaminants (like C. botulinum or grayanotoxins) can be found in some types of honey and should be used cautiously in pregnant or breastfeeding women.
Hypnotherapy, hypnosis: A small study showed potential benefit of a hypnotherapeutic treatment program for patients suffering from recurrent herpes infections on the mouth or face. Further research is needed to confirm these results.
Use cautiously in those with mental illnesses like psychosis, schizophrenia, manic depression, multiple personality disorder, or dissociative disorders. Use cautiously in those with seizure disorders.
Licorice: Laboratory studies have found that deglycyrrhizinated licorice (DGL) may hinder the spread and infection of herpes simplex virus. Studies in humans have been small, but they suggest that topical application of carbenoxolone cream may improve healing and prevent recurrence.
Avoid licorice in those with a known allergy to licorice, any component of licorice, or any member of the Fabaceae (Leguminosae) plant family. Avoid licorice in those with congestive heart failure, coronary heart disease, kidney or liver disease, fluid retention, high blood pressure, or hormonal abnormalities, and in those taking diuretics. Licorice can cause abnormally low testosterone levels in men or high prolactin or estrogen levels in women. This may make it difficult to become pregnant and may cause menstrual abnormalities.
Lysine: Lysine has been claimed to be effective in the treatment and prevention of episodes of recurrent herpes simplex infection. Research results are conflicting at this time. Additional high-quality clinical research is needed to make a conclusion. High-quality studies examining the effect of high doses (>1,000 milligrams) compared to lower doses (<1,000mg) are needed. Also, the effect of reducing arginine in the diet also needs to be determined, as the ratio of lysine to arginine is thought to play a role in the outcome of lysine therapy.
Use cautiously in patients with blood disorders or those using blood thinners, as lysine may increase the risk of bleeding. Use cautiously in patients with diabetes or those who are using agents that lower their blood sugar levels, as lysine may decrease blood sugar levels. Use cautiously in patients taking protein-based drugs, such as aprotinin, as lysine may block the reabsorption of some proteins. Use cautiously in patients with compromised pancreatic function. Use high doses cautiously in patients prone to gallstones. Use cautiously in immunocompromised or immunosuppressed patients, patients with thymus disorders, patients with disorders that alter the metabolism of lysine or other amino acids, patients with high cholesterol, and patients using agents that interact with 5-hydroxytryptamine (5-HT4) receptors (e.g., cisapride, tegaserod). Avoid in patients with liver impairment or kidney disorders.
Ozone therapy: In preliminary research, OzonyTron®, a device used to generate ozone, was used on patients with lip herpes. However, there is not enough evidence to show that ozone therapy can prevent oral herpes infections (cold sores).
The safety of various types of ozone therapy has not been systematically studied. Because ozone is a toxic gas, the safety of ozone therapy has been questioned. A case of death has been reported due to gas embolism. Caution is advised. Serious side effects may occur from the introduction of ozone into the body, including shortness of breath, blood vessel swelling, poor circulation, heart problems, or stroke. Autohemotherapy has been associated with transmission of viral hepatitis and with a possible case of dangerously lowered blood cell counts. Patients are advised to make sure that fresh or sterile needles are used for any medical procedure. Insufflating (blowing into) the ear carries a risk of tympanic membrane (eardrum) damage, and colon insufflation may increase the risk of bowel rupture. There is one case of a patient with HIV becoming psychotic with hallucinations while receiving ozone therapy, but it is not clear that ozone was the cause. It is not recommended to rely on ozone therapies alone to treat potentially dangerous medical conditions. Ozone therapy may lower blood sugar levels. Caution is advised when using medications, herbs, or supplements that may lower blood sugar. Use cautiously in patients with respiratory disorders such as asthma. Ozone therapy is not recommended in pregnant or breastfeeding women, due to a lack of available scientific evidence.
Peppermint: A case study found that topical peppermint oil was effecting in reducing the pain of postherpetic neuralgia. There is currently insufficient research available to determine if there are benefits of peppermint oil in the treatment of postherpetic neuralgia. More high-quality studies are needed in this area.
Use cautiously in patients with gastrointestinal disorders, kidney disorders, liver problems, heart conditions, iron deficiency, sexual dysfunction, hormonal imbalances (for men), glucose-6-phosphate dehydrogenase (G6PD) deficiency, or gallbladder disease, or in patients taking agents for any of these conditions. Use cautiously in patients taking cyclosporine, salicylates, cytochrome P450-metabolized agents, aminophylline, or agents used on the skin, or when used on the skin in combination with a heating pad. Avoid in patients with known allergy to peppermint, its constituents, or other members of the Lamiaceae (Labiatae) family. Avoid excessive consumption of peppermint. Avoid use of peppermint oil around the facial or chest areas of infants and young children, especially around the nose.
Propolis: Laboratory studies report that propolis may have anti-inflammatory effects as well as action against viruses, including herpes simplex virus type 1 and type 2. Early results from poorly designed human studies suggest that propolis used on the skin may improve lesions from genital herpes virus infections. However, without better human research, including comparisons to prescription drugs, firm conclusions cannot be drawn.
There is limited research on propolis for the treatment of eye complications of varicella-zoster, the virus that causes chicken pox or shingles. Some evidence suggests that propolis may speed up healing and improve sight. However, human research is needed before a conclusion can be made.
Avoid if allergic or hypersensitive to propolis, black poplar (Populus nigra), poplar bud, bee stings, bee products, honey, and balsam of Peru. Severe allergic reactions have been reported. Use cautiously in those with asthma or gastrointestinal disorders. Avoid if pregnant or breastfeeding, because of the high alcohol content in some products.
Reishi mushroom: Reishi extract was effective in decreasing postherpetic pain (pain after herpes lesions heal) in one case series. Further research is needed to confirm these results.
Avoid if allergic or hypersensitive to any constituents of Ganoderma lucidum or any member of the Ganodermataceae family. Use cautiously in those with diabetes, blood disorders (including hemophilia), low blood pressure, or ulcers. Avoid if pregnant or breastfeeding.
Rhubarb: One double-blind, controlled trial indicates that topically applied rhubarb-sage extract cream may reduce the symptoms of herpes. More high-quality studies using rhubarb as a monotherapy are needed to discern rhubarb's effect on herpes symptoms.
Avoid if allergic or hypersensitive to rhubarb, its constituents, or related plants from the Polygonaceae family. Avoid using rhubarb for more than two weeks, because it may induce tolerance in the colon, melanosis coli, laxative dependence, pathological alterations to the colonic smooth muscles, and substantial loss of electrolytes. Avoid with atony, colitis, Crohn's disease, dehydration with electrolyte depletion, diarrhea, hemorrhoids, insufficient liver function, intestinal obstruction or ileus, irritable bowel syndrome, menstruation, renal disorders, ulcerative colitis, and urinary problems. Avoid handling rhubarb leaves, as they may cause contact dermatitis. Avoid rhubarb in children under age 12 due to water depletion. Use cautiously in those with bleeding disorders, cardiac conditions, coagulation therapy, constipation, history of kidney stones, or thin or brittle bones. Use cautiously if taking antipsychotic drugs or oral drugs, herbs, or supplements (including calcium, iron, and zinc).
Sage: Early research has shown that sage extracts may prevent the ability of the herpes virus to affect cells. In human research, a product containing sage leaf and other ingredients helped reduce side effects on the skin normally associated with herpes. Additional research is needed in this area.
Use cautiously in patients with hypertension (high blood pressure) or hypotension (low blood pressure), or in patients taking agents that affect blood pressure. Use cautiously in patients with bleeding disorders or in those taking agents that may increase the risk of bleeding. Use cautiously in patients with diabetes or hypoglycemia or in those taking drugs, herbs, or supplements that affect blood sugar. Use cautiously if driving or operating heavy machinery or if taking certain sedatives or antidepressants. Use the essential oil or tincture of sage cautiously in patients with epilepsy. Only sterile preparations of sage should be used in the eye. Avoid use above dietary levels if pregnant or breastfeeding. Avoid if allergic or hypersensitive to sage species, their constituents, or to members of the Lamiaceae family.
Sangre de grado: Sangre de grado has been studied as a treatment for herpes virus infection in patients with AIDS, with positive results. Additional studies are needed before a conclusion can be made.
Avoid with known allergy or sensitivity to sangre de grado or any of its parts.
Shiitake: According to preliminary research, lentinan, a derivative of shiitake, may influence the immune system and reduce the recurrence rate of genital warts. Further well-designed studies are needed to confirm these results. Currently, more proven therapies are recommended.
Avoid if allergic or hypersensitive to shiitake mushrooms.
Siberian ginseng: Limited research suggests that Siberian ginseng may reduce the severity, duration, and frequency of outbreaks of genital herpes after three months of use. Further research is required before conclusions can be made.
Use caution when taking for longer than two months without a 2-3-week break. Caution is advised in patients with bleeding disorders, diabetes, hypoglycemia, blood pressure disorders, autoimmune disorders, psychiatric disorders, or impaired gastrointestinal function, or in those taking agents for any of these conditions. Caution is advised in patients taking central nervous system (CNS) depressants (such as hexobarbital), digoxin, alcohol, ACE inhibitors, antiallergy agents, morphine, estrogens, antidepressants, sedatives, stimulants, or agents processed by the liver's cytochrome P450 enzyme system, p-glycoprotein, or SULT1A3; and in patients undergoing steroid treatment or radiotherapy. Avoid in children and pregnant or breastfeeding women, or with known allergy or sensitivity to Siberian ginseng (Eleutherococcus senticosus, also known as Acanthopanax senticosus), its constituents, related products, or members of the Araliaceae family.
Tai chi: A small trial showed that treatment with tai chi might increase immunity to the virus that causes chicken pox. This may suggest the use of tai chi in the prevention of chicken pox and shingles, but further well-designed large studies must be done before a conclusion can be made.
Avoid with severe osteoporosis or joint problems, acute back pain, sprains, or fractures. Avoid during active infections, right after a meal, or when very tired. Some believe that visualization of energy flow below the waist during menstruation may increase menstrual bleeding. Straining downwards or holding low postures should be avoided during pregnancy, and by people with inguinal hernias. Some tai chi practitioners believe that practicing for too long or using too much intention may direct the flow of chi (qi) inappropriately, possibly resulting in physical or emotional illness. Tai chi should not be used as a substitute for more proven therapies for potentially serious conditions. Advancing too quickly while studying tai chi may increase the risk of injury.
Tea tree oil: Laboratory studies show that tea tree oil has activity against some viruses, and it has been suggested that a tea tree gel may be useful as a treatment on the skin for recurrent herpes labialis. However, there is currently not enough information to make a conclusion on this use of tea tree oil.
Avoid if allergic or hypersensitive to tea tree oil, any of its constituents, balsam of Peru, benzoin, colophony (rosin) tinctures, eucalyptol, or other members of the Myrtle (Myrtaceae) family. Avoid taking tea tree oil by mouth. Avoid if taking antineoplastic agents. Use tea tree oil applied to the skin cautiously in patients with previous tea tree oil use. Avoid if pregnant or breastfeeding.
TENS: Transcutaneous electrical nerve stimulation (TENS) has been used in postherpetic neuralgia. However, there is insufficient evidence from controlled clinical trials upon which to base conclusions.
Avoid with implantable devices, like defibrillators, pacemakers, intravenous infusion pumps, or hepatic artery infusion pumps. Use cautiously in those with decreased sensation, like neuropathy, or seizure disorders. Avoid if pregnant or breastfeeding.
Transfer factor: Some studies have reported improvements, such as shorter duration of pain, in patients with herpes after treatment with transfer factor. Additional high-quality studies are needed in this area.
Use caution in patients with neurological conditions, Wiskott-Aldrich syndrome, diabetes, or hypoglycemia; in pregnant or breastfeeding women; or in those taking agents that affect blood sugar. Avoid with known allergy or sensitivity to transfer factor or any of its constituents. Transfer factor therapy should be provided by a trusted source and supervised by a qualified healthcare provider. Theoretically, transfer factor prepared from cattle that have "mad cow disease" may cause brain and nerve damage. Some preparations of transfer factor may be contaminated with other substances.
Historical or theoretical uses lacking sufficient evidence
Alizarin: Limited evidence suggests that alizarin may improve various herpes infections, including herpes simplex, herpes zoster, induced herpes zoster, and chicken pox. Additional research is needed in this area.
Avoid if allergic or hypersensitive to alizarin or any plants in the Rubiaceae family. Alizarin may be toxic and should not be handled for long periods of time, rubbed in the eyes or eaten. Avoid if pregnant or breastfeeding.
Arabinoxylan: Arabinoxylan is produced from Hyphomycetes mycelia mushroom extract. Arabinoxylan has been used traditionally for herpes zoster infection and postherpetic neuralgia. Arabinoxylan increases immune function and may help the body fight off infection. Clinical studies are needed to support these uses.
Use cautiously in the elderly or those with kidney dysfunction, due to potentially high calcium and phosphorus content. Use cautiously in those with diabetes. Avoid if pregnant or breastfeeding.
Black currant: The black currant shrub is indigenous to Europe and parts of Asia and is particularly popular in Eastern Europe and Russia. Theoretically, black currant may help treat symptoms associated with herpes simplex virus type 1 and type 2, as well as herpes zoster virus. However, further research is necessary.
Use cautiously with venous disorders or gastrointestinal disorders. Avoid if allergic or hypersensitive to black currant, its constituents, or plants in the Saxifragaceae family. Avoid with hemophilia or those on blood thinners unless otherwise recommended by a qualified healthcare provider. Avoid if pregnant or breastfeeding.
Bromelain: Bromelain is a sulfur-containing proteolytic digestive enzyme that is extracted from the stem and the fruit of the pineapple plant (Ananas comosus, family Bromeliaceae). Theoretically, bromelain may be used to treat symptoms associated with herpes, including pain associated with shingles or postherpetic neuralgia. However, clinical research is needed.
Avoid if allergic to bromelain, pineapple, honeybee, venom, latex, birch pollen, carrots, celery, fennel, cypress pollen, grass pollen, papain, rye flour, wheat flour, or other members of the Bromeliaceae family. Use cautiously in those with history of bleeding disorder, stomach ulcers, heart disease, liver or kidney disease. Use caution before dental or surgical procedures or while driving or operating machinery. Avoid if pregnant or breastfeeding.
Bulbous buttercup: Bulbous buttercup (Ranunculus bulbosus) is named for the uniquely bulbous, white protrusion that is found at the base of its stem. Traditionally bulbous buttercup has been used to treat symptoms associated with herpes zoster and shingles, but clinical research is needed to confirm the effectiveness of this treatment. There is currently a lack of high-quality studies on the medicinal applications of bulbous buttercup, and the following safety information is based on traditional use and expert opinion.
Avoid if allergic or hypersensitive to bulbous buttercup. Avoid in patients with compromised liver function, heart conditions, respiratory conditions, diarrhea, vomiting, skin conditions, and gastrointestinal disorders or obstructions. Avoid if pregnant or breastfeeding.
Calendula: Calendula (Calendula officinalis), also known as marigold, has been widely used topically to treat a variety of conditions. Traditionally, calendula has been used topically to treat minor wounds, burns, and other skin problems. According to limited research, calendula may improve symptoms associated with herpetic keratitis and herpes simplex virus infections.
Avoid if allergic to plants in the Aster or Compositae family, such as ragweed, chrysanthemums, marigolds, and daisies. Use cautiously in patients taking sedatives, blood pressure medications, cholesterol medications, blood sugar-altering agents, and immunomodulators. Use cautiously in those with diabetes and in children. Avoid if pregnant or breastfeeding.
Chaparral: Chaparral (Larrea tridentata) is one name for a particular herbaceous woody shrub that grows in the southwestern region of the United States and the northern region of Mexico. Topical preparations of chaparral have been made as lotions in oils to be used to treat chicken pox and genital herpes simplex. Theoretically, chaparral may treat symptoms associated with other herpes simplex viruses, herpes zoster virus, and Epstein-Barr virus. Further research is necessary.
Avoid if allergic to chaparral or any of its components, including nordihydroguaiaretic acid. Use cautiously if taking anticoagulants (blood thinners), blood sugar medications, or drugs that are broken down by the liver (like amiodarone, phenobarbital, valproic acid). Stop use two weeks before surgery or dental or diagnostic procedures with a bleeding risk, and do not use immediately after these procedures. Use cautiously if driving or operating heavy machinery. Avoid if pregnant or breastfeeding.
Eucalyptus oil: Eucalyptus is plant that is native to Australia. In cell cultures, eucalyptus has exhibited antiviral activity against herpes simplex virus type 1. In animal research, eucalyptus oil has been shown to prevent herpes simplex virus type 2 infections. Theoretically, eucalyptus oil may be useful for treating symptoms associated with shingles or herpes virus infections.
Avoid in those allergic to eucalyptus oil or with a history of seizure, diabetes, asthma, heart disease, abnormal heart rhythms, intestinal disorders, liver disease, kidney disease, or lung disease. Use caution if driving or operating machinery. Avoid in those with a history of acute intermittent porphyria. Avoid if pregnant or breastfeeding. A strain of bacteria found on eucalyptus may cause infection. Toxicity has been reported with oral and inhaled use.
Goldenseal: Goldenseal is one of the five top-selling herbal products in the United States and can be found in dietary supplements, eardrops, feminine cleansing products, cold and flu remedies, allergy remedies, laxatives, and digestive aids. According to limited research, goldenseal may used to treat symptoms associated with chicken pox, herpes labialis, cold sores, or herpetic uveitis.
Avoid if allergic or hypersensitive to goldenseal or any of its constituents, like berberine and hydrastine. Use cautiously in those with bleeding disorders, diabetes, or low blood sugar. Avoid if pregnant or breastfeeding.
Physical therapy: Physical therapy is tailored to the patient's condition and health issues. A common goal of physical therapy is to increase how the patient functions at home and at work. According to limited evidence, physical therapy may help treat pain associated with herpes zoster infections and postherpetic neuralgia. However, clinical research is needed to support the use of physical therapy for these indications.
Not all physical therapy programs are suited for everyone, and patients should discuss their medical history with a qualified healthcare professional before beginning any treatments. Physical therapy may aggravate preexisting conditions. Persistent pain and fractures of unknown origin have been reported. Physical therapy may increase the duration of pain or cause limitation of motion. Pain and anxiety may occur during the rehabilitation of patients with burns. Both morning stiffness and bone erosion have been reported in the physical therapy literature, although causality is unclear. Erectile dysfunction has also been reported. Physical therapy has been used in pregnancy and although reports of major adverse effects are lacking the available literature, caution is advised nonetheless. All therapies during pregnancy and breastfeeding should be discussed with a licensed obstetrician or gynecologist before initiation.
St. John's wort: Extracts of Hypericum perforatum L. (St. John's wort) have been recommended traditionally for a wide range of medical conditions. According to limited information, St. John's wort may help treat herpes virus infections.
Rare skin reactions, including rash and itching, have been reported in human studies. Avoid taking if pregnant or breastfeeding.
Stinging nettle: According to limited information, stinging nettle may help reduce symptoms associated with chicken pox and herpes virus infections.
Avoid if allergic or hypersensitive to nettle, the Urticaceae family, or any ingredient of nettle products. Use cautiously in those with diabetes, bleeding disorders, or low sodium levels in the blood. Use cautiously in those using diuretics and anti-inflammatory drugs. The elderly should also use nettle cautiously. Avoid if pregnant or breastfeeding.
Thymus extract: According to limited studies in humans, thymus extract may be used to treat symptoms related to chicken pox, cold sores, cold sore recurrence, and shingles.
Avoid if allergic or hypersensitive to thymus extracts. Use bovine thymus extract supplements cautiously, due to the potential for exposure to the virus that causes "mad cow disease." Avoid use in those with an organ transplant or other forms of allografts or xenografts. Avoid in those receiving immunosuppressive therapy; taking hormonal therapy; or with thymic tumors, myasthenia gravis (a neuromuscular disorder), or untreated hypothyroidism. Avoid if pregnant or breastfeeding; thymic extract increases human sperm motility and progression.
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, it is important to avoid kissing others on the mouth if a herpes viral infection is present.
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 sunblock 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; 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 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 going into labor, the doctor will probably suggest a Cesarean section to reduce the risk of passing the virus to the baby.
In 2002, two clinical trials that tested the efficacy of an HSV-2 vaccine found that the vaccine may reduce the occurrence of HSV-2 disease by approximately 70% in women who were negative for previous HSV-1 or HSV-2 infections. Evidence of efficacy in women who had previously been infected with HSV-1 or in men (HSV-1 positive or negative) was lacking. Based on these results, a larger study (the Herpevac Trial for Women) was conducted more recently to further evaluate the efficacy of this same vaccine in women who were negative for antibodies to HSV-1 and HSV-2. However, according to results from this larger study, the efficacy of the vaccine in preventing genital herpes disease was only 20%. While the vaccine showed a moderate reduction in the rate of HSV-1 infection (35%), a reduction in the rate of HSV-2 infection was lacking.
Human herpesvirus type 3 (varicella-zoster virus, chicken pox)
Varivax®: A vaccine for varicella-zoster infections is now used to prevent chicken pox. Varivax®, a live virus vaccine, produces persistent immunity against chicken pox. Data show that the vaccine can prevent chicken pox 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 chicken pox is now recommended in the United States for all children between the ages of 18 months and adolescence who have not yet had chicken pox. Children are given one dose of the vaccine. Two doses 1-2 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 chicken pox 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 daycare 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, nonpregnant 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-Johnson 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 chicken pox to others. Individuals who have recently been vaccinated should avoid close contact with anyone who might be susceptible to severe complications from chicken pox 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 chicken pox.
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 chicken pox (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 chicken pox months to years after their last vaccination, in all cases, infection was mild, with none of the serious complications of adult chicken pox. 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 chicken pox or those who cannot receive a vaccination of the live virus. Such groups include pregnant women with no history of chicken pox, newborns under four weeks who are exposed to chicken pox 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 chicken pox). VZIG should be given within 96 hours and no later than 10 days after exposure to someone with chicken pox.
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. The vaccine reduced the number of cases of postherpetic neuralgia by 66.5% and reduced the severity and duration of pain and discomfort associated with shingles by 61.1%. In May 2006, the U. S. Food and Drug Administration (FDA) approved the use of Zostavax®. Although Zostavax® has been FDA approved for people 50 years and older, the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) recommends it only for adults aged 60 and older, primarily due to supply concerns. Clinical trials have actually shown that the vaccination is more effective in younger populations (50-59 years, 70% efficacy) compared to older age groups (≥80 years, 20% efficacy).
However, the use of Zostavax® is contraindicated in certain individuals. For instance, Zostavax® should be avoided in individual who have life-threatening allergies to gelatin, the antibiotic neomycin, or other components of the herpes zoster vaccine. In addition, Zostavax® is contraindicated (inadvisable) in individuals with a weakened immune system due to human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS), or any other disease. Patients receiving Zostavax® should not be on other disease medications, such as steroids, radiation, or chemotherapy, that 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 and is not indicated for use in individuals who have previously received Varivax® vaccinations.
Varivax®: Although Varivax® is actually a chicken pox vaccination, its use may reduce the prevalence of shingles in the future. Because shingles is a re-emergence of the same virus that causes chicken pox, people who do not get chicken pox can never get shingles.
Ganciclovir (Cytovene®) is an antiviral medication that is prescribed to individuals with weakened immune systems experiencing CMV retinitis (an infection of the eye that can lead to blindness). In addition, ganciclovir may be prescribed to individuals with acquired immunodeficiency disorders (AIDS) or to those who have received an organ transplant to prevent CMV infection.
Clinical trials have evaluated the use of CMV glycoprotein-B vaccinations to prevent CMV infection. Initially, the vaccine efficacy was evaluated in CMV-negative women within one year of giving birth. According to the results from this study, the women who received the vaccination were less likely to become infected within 42 months of treatment compared to placebo (50% vaccine efficacy). Later, the same vaccine was given with MF59 adjuvant, an immune response stimulator, to patients expecting to receive either a kidney or liver transplant. Results from the study indicated that, for those patients who developed a CMV infection after receiving the transplant, the vaccination reduced the duration of infection and the number of days needed to treat with ganciclovir compared to the control group.