Acute infection with the hepatitis B virus resolves in 95% of adults with no need for specific medical therapy. However, a few cases present as severe hepatitis or acute liver failure, which may require orthotopic liver transplantation or cause death. Under these circumstances, medical therapy that can improve the clinical outcome and improve spontaneous survival would be highly useful; yet, published data regarding the utility of antiviral therapy in acute hepatitis B is quite limited. In this paper, the efficacy and safety of oral nucleoside and nucleotide analogues in the treatment of acute hepatitis B are reviewed, and guidelines for treatment of these acute cases are revisited.