[Question #2743] Ocular Herpes Spread

41 months ago
For a person with recurrent nasal HSV-1 (occurring sometimes about every 50-60 days), for whom the antivirals acyclovir, valacyclovir, and famciclovir all cause some level of unpleasant CNS stimulation/stress/tension and thus are avoided as daily prophylaxis, what are some other means of reducing the frequency of outbreaks? What else can reasonably be done to boost immunity, for example? During an outbreak, a relatively small dose of famciclovir can be tolerated (250mg initial, 125mg every 12 hours for 2.5 days thereafter). Is there some particular reason to fear HSV-1 spread to the eyes in such a person? The potential for ocular spread and associated vision loss causes me enormous anxiety.  Anything you can say to assuage the fear of such a thing will be greatly appreciated. Thanks!
Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
41 months ago
I surely do wish that we had some other mechanism for reducing outbreak frequency or asymptomatic viral shedding, but there are no other proven ways to do this.  Some people have naturopathic treatments that they find helpful but we just don't have enough science to prove that they are successful.
Ocular herpes can happen and it can happen as autoinoculation during a brand new infection (very very rarely happens after an infection is well establshed) or the virus can travel along the top brand of the trigeminal nerve to the eye.  But this is definitely not common or there would be far more concern about ti.  If you did get ocular herpes by some weird and unusual circumstance, it could be treated with antivirals even if you don't find the side effects pleasant.  In the year 2017, I don't think anyone loses their vision due to ocular herpes since treatment is so effective.  And I would also say that for most people, the side effects lessen over time, if they have them at all.  This happens in less than 5% of people who take these medicines. 

Terri
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40 months ago
Regarding the typically diminishing side effects over time: Interestingly, I used to take 500mg valacyclovir daily for many years as a preventive measure. The side effects at that dose were much more tolerable at that time. I did discontinue the daily regimen a couple of years ago as an experiment. Somehow the side effects I experience now when doing my best to treat an outbreak (at that same low dose, mind you) are worse. It can be quite uncomfortable, especially as dosing increases, so I can't imagine what a much higher dose (as I might anticipate for ocular therapy) would entail. I can only hope that I can take something like Ativan concurrently in a situation like that. Or perhaps try foscarnet or even ganciclovir if necessary. It seems rare anyway from your reply.

The epidemiological component of your answer is especially comforting. I assume it applies even in patients that don't treat recurring outbreaks with higher (more typical) dosing of antiviral therapy. My current famciclovir dosing is quite low. Perhaps even those that don't treat outbreaks at all with antiviral therapy can carry the same level of comfort that ocular spread is just exceedingly rare in any case. Therapy isn't necessary or intended to decrease the likelihood of autoinoculation or trigeminal nerve travel/spreading.  Therapy is merely intended to slightly reduce the duration of symptoms. Please confirm.

I have some potential evidence now of spread from the nose to the skin under my nose (where my mustache would be). There is a rough, itchy patch of skin there. Is emergence on the skin rarer? Is it as likely to recur there as a lesion on a mucous membrane? It is troubling to see spread over time initially from the lips to the nose, and now possibly to the skin. Perhaps this is normal evolution.

Thank you for your detailed and patient answers. 

Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
40 months ago
It is really very common for oral herpes to show up in the moustache area and also in the nares.  If you want to know for sure if this is herpes you could have the skin swab tested.  I personally wouldn't describe this as "spread", that's very normal for the virus to be active.  I don't know that we have any real data on the frequency of oral herpes moving to the eye.  But I can tell you, since more than 50% of the US population has HSV 1 infection and the majority  have it orally, the frequency of it going to the eye is very low.  I would encourage you not to spend too much time worrying about this at this point.  If it happens, deal with it then.  There is nothing that you can do about this right now and probably nothing that you need to do. 

Please let me know what other questions you might have.

Terri
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40 months ago
You are right. I need to just let that go. Thank you for your encouragement to do so. One last thing that is current and may help considerably along those lines: I'm being evaluated for marginally low cortisol levels. If I later find that I have to take hydrocortisone supplements, will that impact the frequency and severity of my (already rather frequent it seems) herpes outbreaks and the associated threat of spreading that I need to stop worrying about? :)  I wonder how often it really impacts immunity. Or at what threshold of dosing it clinically matters with HSV-1. Cheers to you Terri. :) 
Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
40 months ago
Cortisone can increase the frequency of outbreaks - you need your immune system to control herpes and cortisone works to suppress the immune response.  It would be best if you are infected to carefully use these medicines to avoid more issues.  And since you don't do well on antivirals, I hope it even more.

Terri
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