Treatment of Genital Herpes Simplex Virus (HSV) Infection
Systemic antiviral medications are the recommended first-line treatment for genital herpes, with specific regimens based on whether it is a first clinical episode or recurrent infection. 1
First Clinical Episode Treatment
For patients experiencing their first episode of genital herpes, the recommended treatment options include:
- Valacyclovir 1 gram orally twice daily for 7-10 days 1
- Acyclovir 400 mg orally three times daily for 7-10 days 2
- Acyclovir 200 mg orally five times daily for 7-10 days 2
- Famciclovir 250 mg orally three times daily for 7-10 days 1
Treatment may be extended if healing is incomplete after 10 days of therapy 2.
Clinical Considerations for First Episodes
- First episodes are typically more severe and prolonged than recurrences
- Early initiation of therapy (within 72 hours of symptom onset) provides maximum benefit 3
- Intravenous therapy may be necessary for severe cases requiring hospitalization 2
- Topical acyclovir is substantially less effective than oral therapy and is not recommended 2
Recurrent Episodes Treatment
Episodic Therapy
For patients with recurrent genital herpes, episodic treatment should be initiated at the earliest sign of prodrome or lesions:
- Valacyclovir 500 mg orally twice daily for 3-5 days 1
- Acyclovir 400 mg orally three times daily for 5 days 2
- Acyclovir 800 mg orally twice daily for 5 days 1
- Acyclovir 800 mg orally three times daily for 2 days 1
- Famciclovir 125 mg orally twice daily for 5 days 1
- Famciclovir 1000 mg orally twice daily for 1 day 1
Suppressive Therapy
For patients with 6 or more recurrences per year, daily suppressive therapy is recommended:
- Valacyclovir 1 gram orally once daily 1, 3
- Valacyclovir 500 mg orally once daily (for patients with ≤9 recurrences per year) 3
- Acyclovir 400 mg orally twice daily 2
- Famciclovir 250 mg orally twice daily 1
Special Populations
HIV-Infected Patients
- Valacyclovir 500 mg twice daily for suppressive therapy 1
- Higher doses and longer duration of therapy may be required 2
- Short-course therapy (1-3 days) should not be used 1
- Close monitoring is recommended as healing may be slower 2
Patients with Renal Impairment
Dose adjustments are required based on creatinine clearance:
| Creatinine Clearance (mL/min) | Valacyclovir Dosing Adjustment |
|---|---|
| ≥50 (normal) | No adjustment needed |
| 30-49 | No adjustment needed |
| 10-29 | 500 mg every 24 hours |
| <10 | 500 mg every 24 hours |
Treatment Efficacy and Monitoring
- Therapy should reduce symptoms, viral shedding, and healing time 3
- Treatment failure should be suspected if lesions do not begin to resolve within 7-10 days 1
- No laboratory monitoring is needed unless the patient has substantial renal impairment 1
- After 1 year of continuous suppressive therapy, consider discontinuation to reassess recurrence frequency 1
Common Pitfalls and Caveats
Delayed Treatment Initiation: Therapy for recurrent episodes must be started at the earliest sign of prodrome for maximum benefit 1
Inadequate Patient Education: Patients should be counseled about:
- Natural history of the disease
- Potential for recurrent episodes
- Asymptomatic viral shedding
- Sexual transmission risk
- Need to abstain from sexual activity when lesions or prodromal symptoms are present 2
Mismanagement of Suppressive Therapy:
Overlooking Renal Function: Ensure adequate hydration and dose adjustment for patients with renal impairment 1
Unrealistic Expectations: Patients should understand that antiviral medications control symptoms but do not eradicate latent virus or prevent all recurrences 2
Conclusion
Genital herpes treatment requires a tailored approach based on whether it is a first episode or recurrent infection, frequency of recurrences, and patient-specific factors such as HIV status and renal function. Valacyclovir and acyclovir remain the cornerstone of therapy, with dosing regimens that vary according to the clinical scenario.