What is the treatment for Herpes Simplex 2 (HSV-2)?

Treatment for Herpes Simplex 2 (HSV-2)

For HSV-2 infections, oral antiviral medications including acyclovir, valacyclovir, or famciclovir are the recommended treatments, with specific regimens depending on whether it's a first episode, recurrent episode, or suppressive therapy is needed. 1

First Clinical Episode Treatment

For patients experiencing their first clinical episode of genital HSV-2, the following regimens are recommended:

• Acyclovir 400 mg orally three times a day for 7-10 days, OR
• Acyclovir 200 mg orally five times a day for 7-10 days, OR
• Famciclovir 250 mg orally three times a day for 7-10 days, OR
• Valacyclovir 1 g orally twice a day for 7-10 days 1

Note: Treatment may need to be extended if healing is incomplete after 10 days.

Recurrent Episodes Treatment

For recurrent episodes, shorter courses of therapy are effective:

• Acyclovir 400 mg orally three times a day for 5 days, OR
• Acyclovir 800 mg orally three times a day for 2 days 2, OR
• Famciclovir 125 mg orally twice daily for 5 days, OR
• Valacyclovir 500 mg orally twice daily for 3-5 days 3

Suppressive Therapy

For patients with frequent recurrences (≥6 per year), daily suppressive therapy is recommended:

• Valacyclovir 1 gram once daily, OR
• Acyclovir 400 mg orally twice daily, OR
• Famciclovir 250 mg orally twice daily 1, 3

Suppressive therapy has been shown to reduce recurrence frequency by ≥75% and can reduce the risk of transmission to uninfected partners by approximately 50% 4.

Special Considerations

HIV Co-infection

• HIV-infected patients may require longer courses of therapy and closer monitoring
• For severe cases, initial treatment with IV acyclovir may be necessary 1
• Oral treatment options:
  • Valacyclovir 500 mg twice daily
  • Famciclovir 500 mg twice daily
  • Acyclovir 400-800 mg 2-3 times daily 1

Acyclovir-Resistant HSV

If treatment failure is suspected due to resistance (lesions not resolving within 7-10 days):

• Obtain viral culture and susceptibility testing
• Intravenous foscarnet (40 mg/kg three times daily) is the treatment of choice for acyclovir-resistant HSV 5

Pregnancy

• Acyclovir is generally considered safe during pregnancy
• Valacyclovir and famciclovir have less data but may be used when benefits outweigh risks

Patient Education and Counseling

Important counseling points include:

• HSV-2 is a recurrent, incurable viral disease
• Antiviral medications control symptoms but do not eliminate latent virus
• Abstain from sexual activity when lesions or prodromal symptoms are present
• Transmission can occur during asymptomatic viral shedding
• Use condoms consistently to reduce transmission risk
• Suppressive therapy reduces but does not eliminate asymptomatic viral shedding 1
• Partners should be informed about infection status

Treatment Pitfalls to Avoid

1. Delayed treatment initiation: Treatment is most effective when started during the prodromal phase or within 24 hours of lesion appearance
2. Inadequate dosing: Using lower doses than recommended reduces effectiveness
3. Topical therapy: Topical acyclovir is substantially less effective than oral therapy and is not recommended 1
4. Failure to consider resistance: In immunocompromised patients with poor response to standard therapy, consider acyclovir resistance
5. Neglecting patient education: Proper counseling about transmission prevention is essential for disease control

Remember that while HSV-2 cannot be cured, appropriate antiviral therapy can significantly reduce symptoms, accelerate healing, and decrease the risk of transmission to sexual partners.