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

Treatment of Herpes Simplex Virus Type 2 (HSV-2)

For the treatment of HSV-2 infections, valacyclovir 500 mg twice daily for 5 days is recommended as first-line therapy for recurrent episodes, with treatment started within the prodrome or within 2 days of lesion onset for maximum benefit. 1

First Clinical Episode Treatment

For patients experiencing their first clinical episode of genital herpes:

• First-line options:

  • Valacyclovir 1 gram twice daily for 7-10 days 1
  • Acyclovir 400 mg orally three times daily for 7-10 days 1
  • Acyclovir 200 mg orally five times daily for 7-10 days 2

• For severe cases requiring hospitalization:

  • Intravenous acyclovir 5-10 mg/kg body weight every 8 hours for 5-7 days or until clinical resolution 1

Recurrent Episodes Treatment

For patients with recurrent genital herpes episodes:

• First-line options:

  • Valacyclovir 500 mg twice daily for 5 days 1, 3
  • Valacyclovir 1 gram once daily for 5 days 3
  • Acyclovir 800 mg twice daily for 5 days 1

• Alternative shorter course:

  • Acyclovir 800 mg three times daily for 2 days has been shown to significantly reduce the duration of lesions, episodes, and viral shedding 4

Suppressive Therapy

For patients with frequent recurrences (≥6 episodes per year):

• First-line options:
  • Valacyclovir 1 gram once daily 1, 3
  • Valacyclovir 500 mg once daily (for patients with ≤9 recurrences per year) 1, 3
  • Acyclovir 400 mg twice daily 1, 3

Special Populations

HIV-Infected Patients

• Valacyclovir 500 mg twice daily is recommended for suppressive therapy 1, 3
• Higher dosing and more frequent monitoring for breakthrough outbreaks may be necessary 1
• Treatment failures occur more frequently, and healing may be slower 2

Patients with Renal Impairment

Dose adjustments for valacyclovir based on creatinine clearance:

• CrCl ≥50 mL/min: No adjustment needed
• CrCl 30-49 mL/min: No adjustment needed
• CrCl 10-29 mL/min: 500 mg every 24 hours
• CrCl <10 mL/min: 500 mg every 24 hours 1

Transmission Reduction

• Daily valacyclovir 500 mg for the infected partner reduces the risk of transmission to susceptible partners by 48-75% 1, 3
• Valacyclovir has been shown to reduce asymptomatic viral shedding and recurrence rates 1, 3
• Consistent condom use during all sexual encounters significantly reduces HSV-2 transmission risk 1

Important Clinical Considerations

• Patients should be educated about:

  • Prodromal symptoms (tingling, burning, itching) that may precede outbreaks
  • The need to abstain from sexual contact during outbreaks or when prodromal symptoms are present
  • Asymptomatic viral shedding and transmission risk 1

• Antiviral medications do not eradicate latent virus or prevent subsequent recurrences after discontinuation 2, 5

• Treatment is most effective when started within the prodromal phase or within 48 hours of lesion onset 1, 4

• Topical acyclovir is substantially less effective than oral therapy and its use is discouraged 2

• Patients on suppressive therapy should be followed up within 3-6 months to assess tolerance and effectiveness, with annual reevaluation of the need for continued therapy 1

• Monitor for potential adverse effects, particularly in patients receiving intravenous therapy, including renal function changes and adequate hydration during treatment 1