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Mucocutaneous HSV / VZV

SSTI / Viral

Source: IDMP View on spectrum chart →
Patient + scenario modifiers
Patient
Clinical scenario / source

Annotations only — chart still shows the full chemistry of each drug.

1. Clinical Syndrome

Skin and mucosal disease caused by herpes simplex virus (HSV-1 orolabial, HSV-2 genital) or varicella-zoster virus (primary varicella, herpes zoster reactivation). Includes orolabial herpes, genital herpes, herpetic whitlow, herpes gladiatorum, eczema herpeticum, herpes zoster (shingles), disseminated zoster.

Excludes: HSV encephalitis (separate syndrome), neonatal HSV (separate workflow with IV ACV 20 mg/kg q8h × 21 d), VZV pneumonitis or vasculopathy (specialty cases), CMV / EBV mucocutaneous disease (different ladder).

2. Pathogens

Consider the patient: Immunocompetent vs immunocompromised (latter → broader, longer courses, higher risk of dissemination + resistance), age (zoster risk rises with age + immunosenescence), pregnancy (acyclovir / valacyclovir Category B; preferred PO antiviral), atopic dermatitis (eczema herpeticum risk).

Consider the case: Initial vs recurrent episode (initial worse, longer course), localized vs disseminated (>20 vesicles outside primary dermatome = disseminated zoster — IV + isolation), ophthalmic involvement (V1 zoster — emergent ophtho), encephalitis suspicion (separate workflow).

Common

    • Herpes Simplex Virus 1

      Orolabial > genital. Latency in trigeminal ganglion. Recurrent cold sores; herpetic whitlow (finger); herpes gladiatorum (wrestlers); eczema herpeticum.

    • Herpes Simplex Virus 2

      Genital > orolabial. Latency in sacral ganglia. Initial episode often severe; recurrences shorter. Chronic suppression reduces transmission ~50%.

    • Varicella-Zoster Virus

      Primary varicella (chickenpox — generalized vesicular rash) or reactivation as herpes zoster (dermatomal rash + pain). Post-herpetic neuralgia common.

3. Empiric Therapy

TierFirst choiceAlternativesDurationComments
Outpatient
  • 1 g · PO TID × 7 days (zoster) OR 1 g BID × 10 days (genital HSV initial) · PO
  • 500 mg PO TID (zoster) OR 1 g PO BID × 1 d (HSV episodic) · — · PO
  • 800 mg 5×/day × 7 d (zoster) OR 400 mg TID × 10 d (HSV initial) · PO · PO

    PO 5×/day dosing → adherence challenge. VACV / FCV preferred.

**Zoster: 7 days.** **Initial genital HSV: 10 days.** **Episodic recurrent HSV: 3–5 days** (or single-day FCV). **Chronic suppression: indefinite** (VACV 500 mg–1 g daily).**Start within 72 h of rash onset for zoster** — max benefit at 24–48 h. **Initial genital HSV** is typically severe (systemic symptoms common); reassure that recurrences are usually milder. **Eczema herpeticum** in atopic dermatitis is a derm emergency — IV ACV + ophtho if periocular. **Chronic suppression** reduces recurrence ~70% + transmission to partner ~50%.
Admitted to ward
  • 10 mg/kg · q8h × 7–10 days (slow IV infusion ≥1 h, hydrate to 1.5× maintenance) · IV
  • 40 mg/kg · q8h · IV

    ACV-resistant HSV / VZV (rare; mostly immunocompromised on chronic suppression).

7–10 days for disseminated zoster + severe mucocutaneous; longer for immunocompromised**Disseminated zoster** (>20 vesicles outside primary dermatome), **severe immunocompromised varicella / zoster**, **ophthalmic zoster with V1 + nasociliary involvement in immunocompromised**, **severe initial HSV in immunocompromised**. **Airborne + contact precautions** for disseminated VZV / varicella until all lesions crusted. **IV → PO step-down** when stable + lesions crusting.

4. Directed Therapy

Drug choice by syndrome:

  • Orolabial HSV recurrent: VACV 2 g BID × 1 day (Famvir 1 g BID × 1 day equivalent) — single-day options preferred.
  • Genital HSV initial: VACV 1 g BID × 10 d, or ACV 400 mg TID × 10 d.
  • Genital HSV episodic recurrent: VACV 500 mg BID × 3 d (or 1 g daily × 5 d).
  • Genital HSV chronic suppression: VACV 500 mg–1 g daily indefinitely.
  • Herpes zoster, immunocompetent: VACV 1 g TID × 7 d (or FCV 500 mg TID × 7 d, or ACV 800 mg 5×/d × 7 d).
  • Disseminated zoster / severe / immunocompromised: ACV 10 mg/kg IV q8h × 7–14 d.
  • Ophthalmic zoster (V1): emergent ophthalmology + VACV 1 g TID × 7 d (extend to 14 d in immunocompromised); IV ACV if immunocompromised or active corneal involvement.
  • Primary varicella, adult: VACV 1 g TID × 5–7 d; IV ACV if severe / pneumonitis / encephalitis / immunocompromised.
  • Eczema herpeticum: IV ACV + cover staph (vanc + clindamycin or TMP-SMX) + derm urgent.
  • ACV-resistant HSV / VZV: foscarnet 40–60 mg/kg q8h IV.

Adjuncts:

  • Steroids in zoster: controversial; not routinely recommended (modest benefit for acute pain, no PHN reduction; risks > benefits in immunocompromised).
  • Post-herpetic neuralgia (PHN): gabapentinoids (gabapentin titrate to 1800–3600 mg/d, pregabalin 150–600 mg/d), TCAs (amitriptyline / nortriptyline 25–100 mg qhs), topical lidocaine 5% patch, topical capsaicin, opioids reserved.
  • Pain control during acute zoster: NSAIDs + acetaminophen ± gabapentinoid early.
  • Vaccination prevention: Shingrix (recombinant adjuvanted, 2-dose) for adults ≥50 + immunocompromised ≥19 — far superior to old Zostavax (discontinued).

5. Monitoring

Resolution: lesion crusting (typically 7–10 days for zoster), pain reduction, no new dermatomes / vesicles. PHN can persist months post-rash — pain management.

Toxicity: ACV/VACV → Cr + mental status; foscarnet → daily Mg/Ca/Cr/K. Hydration for IV ACV mandatory.

Resistance: ACV-resistant HSV/VZV uncommon in immunocompetent; rises in HSCT / advanced HIV on chronic suppression. Suspect with non-healing or new lesions despite appropriate ACV dosing.

Pearls

Start within 72 h of zoster rash for maximum benefit. Single-day VACV or FCV transformed episodic HSV adherence. Eczema herpeticum is a derm emergency — IV ACV + staph coverage + derm consult; atopic dermatitis precipitant. Hutchinson sign (zoster lesions on tip of nose) → V1/ophthalmic involvement → emergent ophthalmology. Disseminated zoster = >20 vesicles outside primary dermatome → airborne + contact precautions + IV ACV. Shingrix vaccine is the prevention story — much more effective than ACV chronic suppression for older adults. Chronic suppression reduces partner transmission in HSV-2 — important counseling point.

References