Herpes Simplex Virus Type 1 (HSV-1) in Burn Patients Prevention Versus Treatment: Finding The Right Balance

Abstract

Herpes simplex virus type 1 (HSV-1) is an under-recognized but clinically important pathogen in the burn population. Burn injury causes a unique and sustained alteration of innate and adaptive immunity and destroys the dermal barrier that normally contains mucocutaneous herpesvirus reservoirs; these factors predispose to HSV-1 reactivation and primary or secondary infection of burns and graft sites. HSV-1 in burn patients may present as delayed wound healing, necrotic graft loss, fever of unclear source, or atypical vesiculoulcerative lesions and can be mistaken for bacterial infection or ischemic tissue necrosis. Management options fall broadly into prevention (infection control, screening, and antiviral prophylaxis) and treatment (topical and systemic antivirals, surgical management, and management of antiviral resistance). The evidence base is limited and heterogeneous: case reports and small series document clinically significant wound HSV-1 infection causing graft failure and worsened scarring, systematic reviews summarize the inconsistency of outcome data, and randomized trials in related critically ill populations have questioned the benefit of routine preemptive systemic antiviral strategies. Prophylactic acyclovir is widely used in facial resurfacing and is practiced in some burn centers particularly for facial burns and in patients with large TBSA burns or prolonged intubation but no multicenter randomized trial has established a universal recommendation specifically for burn patients. Conversely, early targeted treatment of confirmed HSV-1 infection with systemic acyclovir or, in resistant cases, foscarnet, is associated with rapid clinical improvement and salvage of grafts in published series. Practical decision-making therefore requires balancing the (low) risk and cost of prophylaxis and the rare but serious consequences of HSV wound disease, while accounting for local HSV prevalence, patient risk factors (facial burns, immunosuppression, prolonged mechanical ventilation, steroid use), diagnostic capacity (PCR, immunohistochemistry), and stewardship concerns (resistance, nephrotoxicity). In this article we synthesize contemporary evidence, review diagnostic and therapeutic options, discuss prevention strategies, and propose a pragmatic, risk-stratified algorithm for clinicians in burn units to achieve the optimal prevention–treatment balance for HSV-1 in burn patients.