What is the first line treatment for herpes infections?

First-Line Treatment for Herpes Infections

The first-line treatment for herpes infections is oral antiviral therapy with acyclovir, valacyclovir, or famciclovir, with specific regimens depending on whether it's a first clinical episode or recurrent infection. 1

First Clinical Episode Treatment

For patients presenting with a first clinical episode of genital herpes, the recommended regimens include:

• 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

Treatment may need to be extended if healing is incomplete after 10 days of therapy.

Recurrent Episodes Treatment

For recurrent episodes, shorter courses are effective:

• Acyclovir 400 mg orally three times a day for 5 days, OR
• Acyclovir 200 mg orally five times a day for 5 days, OR
• Acyclovir 800 mg orally twice a day for 5 days, OR
• Famciclovir 125 mg orally twice a day for 5 days, OR
• Valacyclovir 500 mg orally twice a day for 5 days 1

Suppressive Therapy

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

• Acyclovir 400 mg orally twice a day, OR
• Famciclovir 250 mg orally twice a day, OR
• Valacyclovir 250 mg orally twice a day, OR
• Valacyclovir 1 g orally once daily 1

Medication Considerations

Valacyclovir

Valacyclovir is a valine ester of acyclovir with enhanced oral bioavailability, allowing for less frequent dosing compared to acyclovir. Clinical trials have demonstrated that valacyclovir is as effective as acyclovir in treating genital herpes, with the advantage of twice-daily dosing 2, 3.

Famciclovir

Famciclovir is a prodrug of penciclovir with high oral bioavailability. It has shown efficacy in treating recurrent genital herpes with a convenient twice-daily dosing schedule 4.

Acyclovir

While effective, acyclovir typically requires more frequent dosing (up to five times daily), which may affect patient adherence 1, 5.

Important Clinical Considerations

• Initiate treatment early: For maximum efficacy, treatment should be started within 72 hours of symptom onset for first episodes, and ideally within 24 hours for recurrent episodes 1.

• Topical therapy is not recommended: Topical acyclovir is substantially less effective than systemic therapy and is discouraged 1.

• Treatment does not eradicate the virus: Antiviral medications control symptoms but do not eliminate latent virus or prevent future recurrences after discontinuation 1.

• Patient counseling is crucial: Patients should be informed about:

  • Natural history of herpes infections
  • Risk of transmission during asymptomatic viral shedding
  • Importance of abstaining from sexual activity during outbreaks
  • Using condoms to reduce transmission risk
  • Informing sexual partners about their infection 1

• Special populations: Higher dosages of acyclovir (400 mg orally five times a day) may be needed for herpes proctitis or oral infection 1.

Common Pitfalls to Avoid

1. Delayed treatment: Starting therapy too late reduces efficacy. Patients with recurrent episodes should have medication on hand to start at the first sign of prodrome.

2. Inadequate counseling: Failing to counsel patients about transmission risk during asymptomatic periods.

3. Overlooking type-specific testing: HSV-1 vs. HSV-2 identification has prognostic importance, as HSV-1 causes fewer recurrences.

4. Not considering suppressive therapy: For patients with frequent recurrences, suppressive therapy can significantly improve quality of life by reducing recurrence frequency by ≥75%.

5. Discontinuing suppressive therapy too soon: After 1 year of continuous suppressive therapy, reassess the need based on recurrence frequency and psychological impact.