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HSV2 Pain Management


Here’s a question I recently received that I thought everyone could benefit from:

“Hey Andrew,

I had a patient in Family Practice clinic who was 20yo and had a HSV2 outbreak. I started her on treatment but the problem was she is a cheerleader, so of course she is active. On exam she was VERY tender. Have you found anything that will help with the pain until the antivirals take effect?


There’s a couple things you should be aware of regarding HSV outbreaks. The first outbreak is usually the worst (severity and duration). All patients should start antiviral therapy as soon as possible and no later than 72 hours.

Typically, patients should have antivirals on hand (for those who have recurrent outbreaks) so they can start medication at the first sign of disease (typically pain/tingling).  All antivirals seem to have similar efficacy and I typically use acyclovir simply because of cost.

As far as pain management, I typically give ibuprofen 600mg every 6 hours. Most patients do fine with this. There are, however, occasional cases that may require stronger pain medication. When there is a severe outbreak or the patient calls saying the ibuprofen doesn’t provide relief, then I typically give Tramadol.

I’ll dose the Tramadol at 50mg, 1-2 tabs every 6-8 hours. There are many people who are hesitant to use controlled substances, but you have to treat your patient. Pain is real. Make your patient comfortable!

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