Treatment Options for Recurrent Genital Herpes
For recurrent genital herpes, oral antiviral medications are the mainstay of treatment, with famciclovir 1000 mg twice daily for 1 day or valacyclovir 500 mg twice daily for 3 days being the most effective options for episodic therapy, while valacyclovir 250 mg twice daily or 500 mg once daily is recommended for suppressive therapy. 1, 2
Episodic Treatment Options
Oral Medications
- First-line options:
Famciclovir: 1000 mg twice daily for 1 day 2
- Reduces median healing time to 4.3 days compared to 6.1 days with placebo
- 23% of patients had aborted lesions (no progression beyond erythema) vs. 13% with placebo
- Median time to loss of all symptoms: 3.3 days vs. 5.4 days with placebo
Valacyclovir: 500 mg twice daily for 3 days 1
- Better bioavailability than acyclovir
- Requires fewer daily doses, improving compliance
Acyclovir: 800 mg three times daily for 2 days 3
- Significantly reduces duration of lesions (median 4 days vs. 6 days with placebo)
- Increases proportion of aborted episodes
- Alternative: 800 mg twice daily for 5 days 4
Topical Treatments
- Acyclovir cream 5%: Apply 5 times daily for 4 days 1
- Start treatment within 1 hour of symptom onset when possible
- Most effective when initiated during prodrome or early lesion stage
- Less effective than oral therapy but may be used as adjunctive treatment
Suppressive Therapy
Indicated for patients with ≥6 recurrences per year:
Valacyclovir: 250 mg twice daily or 500 mg once daily 1, 5
- 81% of patients remain recurrence-free after 3 months of therapy
- Recurrence-free rates remain stable at 84-91% through 12 months
- Well-tolerated with minimal side effects
- Once-daily dosing may improve compliance 5
Famciclovir: 250 mg twice daily 2
- 60-65% of patients remain on therapy at 12 months
- 29% recurrence-free at 12 months (vs. 6% with placebo)
- Approximately one-fifth the median number of recurrences compared to placebo
Special Populations
Renal Impairment
Dose adjustments required based on creatinine clearance 1:
| Creatinine Clearance (mL/min) | Valacyclovir Dosing (Genital Herpes Recurrent) |
|---|---|
| ≥50 (normal) | 500 mg every 12 hours |
| 30-49 | No reduction |
| 10-29 | 500 mg every 24 hours |
| <10 | 500 mg every 24 hours |
HIV-Infected Patients
- Higher doses recommended for HIV-infected patients 1
- Famciclovir 500 mg twice daily for 7 days is comparable to acyclovir 400 mg 5 times daily 2
- For suppressive therapy in HIV patients: valacyclovir 500 mg twice daily 1
Symptomatic Relief
- Topical anesthetics
- Sitz baths with warm water
- Oral analgesics
- Keep lesions clean and dry 1
Patient Education
- Critical points:
- Apply medication at first sign of prodrome
- Wash hands before and after application
- Continue treatment for full prescribed duration even if symptoms improve
- Abstain during outbreaks or prodromal symptoms
- Use condoms consistently to reduce transmission risk
- Be aware of asymptomatic viral shedding and transmission risk 1
Clinical Pearls and Pitfalls
- Early treatment is crucial: Initiate therapy within 6 hours of first symptoms for maximum effectiveness 2
- Aborted lesions: Successful treatment can prevent lesions from progressing beyond the papule/erythema stage 2
- Compliance considerations: Shorter treatment courses (1-3 days) and fewer daily doses improve adherence
- Common mistake: Waiting too long to initiate therapy reduces effectiveness
- Treatment failure: Consider resistance in immunocompromised patients with poor response to standard therapy