Recommended Medications for HSV Outbreak
For an active HSV outbreak, the recommended first-line treatment is oral acyclovir 400 mg three times daily for 5 days, or oral acyclovir 200 mg five times daily for 5 days, or oral acyclovir 800 mg twice daily for 5 days. 1
First-Line Treatment Options for Active Outbreaks
Acyclovir Options
- Oral acyclovir 400 mg three times daily for 5 days
- Oral acyclovir 200 mg five times daily for 5 days
- Oral acyclovir 800 mg twice daily for 5 days 1
Alternative Options
- Valacyclovir 500 mg twice daily for 5 days (or 1 gram twice daily for 1 day)
- Famciclovir 125 mg twice daily for 5 days 1
Treatment Selection Based on Clinical Scenario
For First Episode Genital Herpes
- Use higher doses and longer duration (7-10 days) of the above medications
- Consider IV acyclovir 5-10 mg/kg every 8 hours for severe cases 1
For Recurrent Episodes
- Start treatment within the prodrome or within 2 days of lesion onset for maximum benefit
- Oral acyclovir 800 mg twice daily for 5 days is recommended 1
Suppressive Therapy Options
For patients with frequent recurrences (≥6 per year), suppressive therapy should be considered:
- Valacyclovir 500 mg orally once daily (first-line option)
- Acyclovir 400 mg orally twice daily
- Famciclovir 250 mg orally twice daily 1
Valacyclovir is the only antiviral approved for once-daily suppressive therapy, which may improve adherence 2. Daily valacyclovir reduces the risk of transmission to susceptible partners by 50-75% and reduces asymptomatic viral shedding and recurrence rates 1.
Special Considerations
Renal Impairment
Dose adjustments are required for patients with renal impairment:
| Creatinine Clearance (mL/min) | Valacyclovir Dosing |
|---|---|
| ≥50 (normal) | No adjustment needed |
| 30-49 | No adjustment needed |
| 10-29 | 500 mg every 24 hours |
| <10 | 500 mg every 24 hours |
| [1,3] |
HIV Co-infection
- Consider higher dosing of valacyclovir (500 mg twice daily)
- More frequent monitoring for breakthrough outbreaks 1
Acyclovir-Resistant HSV
In immunocompromised patients who develop resistance to acyclovir (and related drugs):
- Foscarnet 40 mg/kg IV three times daily or 60 mg/kg twice daily for 10 days
- Cidofovir may be considered if foscarnet fails 4
Patient Education
- Advise abstinence during active outbreaks or prodromal symptoms
- Educate about potential prodromal symptoms (tingling, burning, itching)
- Inform about asymptomatic viral shedding and transmission risk
- Encourage consistent condom use during all sexual encounters 1
Comparative Efficacy
Valacyclovir appears to be somewhat better than famciclovir for suppression of genital herpes and associated viral shedding 5. In one study, HSV was detected on 3.2% of days among famciclovir recipients compared to 1.3% of days among valacyclovir recipients 5.
Monitoring
- Follow up within 3-6 months for patients on suppressive therapy
- Reassess need for continued suppressive therapy annually
- Monitor for complications such as secondary bacterial infection
- Assess response to therapy within 72 hours 1