If a patient has a known history of Herpes Simplex 1 and elects to have laser resurfacing using ablative and fractional techniques, what is the standard for pre and post medication and follow-up? There seems to be a lot of confusing information out there. If a patient does, in fact, experience a herpes flare-up, could it be due to inadequate pre-medication and post-medication? I am searching for some " standard of practice". The laser procedure was performed by an RN.
Is There an Existing Standard for Pre/post Laser Resurfacing Meds for a Patient with HV?
Doctor Answers 5
Laser Resurfacing and Herpes Virus
Thank you for your question. There are general guidelines from the drug manufacturers of pre treatment for those with a known history of Herpes breakout, and those without. Different physicians have their own formula of success and some prescribe, Valcyclovir, Famcylovir, Acyclovir, and at different doses, and number of days of duration, and different number of days prior to treatment. During an active breakout, the dosing varies. Be certain to be under the supervision of a board certified dermatologist or plastic surgeon with expertise in laser surgery for the most effective and safe treatments. I hope this helps.
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Antiviral treatment against herpes during facial laser resurfacing
If a patient has a history of recurrent herpes simplex virus episodes (fever blisters or cold sores) and will be undergoing facial laser resurfacing, dermabrasion (not microdermabrasion) or a medium or deep depth chemical peel, then treatment with an antiviral medication (Famvir, Valtrex, Acylovir,etc) is worthwhile to help prevent an outbreak which can develop into multiple blisters on the raw skin.
Since most of the population has been exposed to the virus, even if they have never had an episode of a fever blister, many doctors would treat them prior to and after facial resurfacing if a wound is created. This is because the virus may become activated during trauma or stress, such as laser resurfacing. Fraxel Repair, being a carbon dioxide wavelength, is in this category, but Fraxel Restore and Dual, may not require prophylaxis if there is no history of cold sores. The doctor may not prescribe the medication with Fraxel Restore if the laser will not treat the area in which the fever blisters break out. As an example, if there are cold sores near the lip, but only the cheeks will be treated, the doctor may elect to only treat with antiviral medication if a cold sore then erupts after treatment.
It is important for all facial resurfacing patients to notify their doctor if pain in the skin develops during the healing process as this may indicate a herpes outbreak.
Prophylaxis of Herpes Virus During Laser Resurfacing
As already mentioned there are alot of different medications and regimens that are recommended. There are also different opinions about who should be treated with anti-virals following laser resurfacing. All patients? Patients with recent cold sore? Patients with distant history of cold sores? This is typically based on training and personal experience. I am very conservative and treat all CO2 laser resurfacing patients with Valtrex before and one week after treatment. However, I am unaware of a "standard" treatment in this instance. I hope this helps.
Stephen Weber MD, FACS
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Viral prophylaxis for laser resurfacing. Standards?
Pardon my cynicism, but this question sounds like "ammunition-gathering" for a complaint or lawsuit. Even if a RN performed your procedure, he or she was supervised by a physician who should be knowledgeable about the procedure being performed, and the laser being utilized. Since registered nurses do not have independent prescribing privileges, any medications would also have been prescribed by this physician, according to his or her best judgement, experience, and perhaps established protocols.
I routinely prescribe Zovirax for all laser resurfacing patients (and some facial peel patients), starting 2 days before the procedure, and continuing for 8 days after surgery. If the patient is not healed by then (the vast majority are with proper wound care), I can extend the prescription. If any sign of viral outbreak is noted, the dose is doubled or tripled, and Zovirax ointment is added. Keflex (if not allergic) is also used for 5 days post-op--more if needed for bacterial prophylaxis while healing.
Other laser experts prefer Valtrex, or other medication regimens, and may prescribe longer or less so, depending on training, experience, and habit.
There is no "standard" protocol, and viral flare-ups may be due to innate viral "loads," individual patient immune status, less-than-rigorous wound care, contamination or exposure to another viral carrier, and numerous other factors. They can simply occur as a response to stress or surgical "injury," and can happen in anyone who has had chicken pox as a child--the virus remains in your body, and can resurface as "cold sores" or "shingles."
I have found that careful and close monitoring during the healing phase (i.e., seeing the patient in re-check every few days until healed) allows me to follow the healing progress, adequacy of wound care and patient compliance, and allows me to tailor any medication changes to the individual patient's needs, rather than simply doing a procedure, following a preprinted protocol, and not seeing the patient in follow-up for a week or two. However, that level of care and 1-on-1 physician-patient interaction is more costly than a spa laser treatment by a RN.
However, even spa laser treatments are generally quite straight forward, minimally risky, and with few complications. Herpes outbreak can occur randomly even without undergoing a laser treatment, as you know, so this is less an issue of inadequate medication and more a direct result of random occurrence or even patient choice of provider (usually based on cost, rather than what are "best practices.")
I'm sorry you had trouble with this virus as you healed, but the good news is that most patients have no permanent scarring or other untoward problems long-term with proper treatment once the viral outbreak is diagnosed. Keep following your provider's advice, and stay out of the sun until all pinkness is gone. Best wishes! Dr. Tholen
Pre and post care for laser patients with Herpes Simplex I
I recommend that any patients who have Herpes Simplex I take a regular, daily course of Acyclovir (Zovirax) to avoid flare-ups in general. There is nothing a provider can do to prevent you from having a flare-up as far as the pre and post treatment goes or how they perform the treatment, but trauma to the lip area in general can cause a flare-up, so if you don't normally take a medication daily to avoid flare-ups in general, you should take a pill a day for a couple of days before a laser treatment as well as a couple of days after.