What are the oral and topical treatment options for recurrent genital herpes?

Treatment Options for Recurrent Genital Herpes

For recurrent genital herpes, the recommended treatment is valacyclovir 500 mg twice daily for 3 days or 1000 mg once daily for 5 days for episodic treatment, and valacyclovir 500-1000 mg once daily for suppressive therapy based on recurrence frequency. 1, 2

Oral Treatment Options

Episodic Treatment

Episodic treatment should be initiated at the first sign of prodrome or lesions:

• Valacyclovir options:

  • 500 mg twice daily for 3 days (FDA-approved 3-day regimen) 2
  • 1000 mg once daily for 5 days (equivalent efficacy to 500 mg twice daily) 3

• Acyclovir options:

  • 400 mg three times daily for 5 days 1, 4
  • 800 mg twice daily for 5 days 4

• Famciclovir option:

  • 125 mg twice daily for 5 days 1, 2

Suppressive Therapy

For patients with ≥6 recurrences per year, suppressive therapy is recommended:

• Valacyclovir options:

  • 500 mg once daily (for patients with <10 recurrences per year) 5, 6
  • 1000 mg once daily (for patients with ≥10 recurrences per year) 5

• Acyclovir option:

  • 400 mg twice daily 5, 7

• Famciclovir option:

  • 250 mg twice daily 2

Topical Treatment Options

• Acyclovir cream 5%:
  • Apply 5 times daily for 4 days
  • Most effective when started during prodrome or early lesion stage 1
  • Start treatment within 1 hour of symptom onset when possible

Special Considerations

Renal Dosage Adjustments

For patients with renal impairment, dose adjustments are necessary:

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]

Symptomatic Relief

In addition to antiviral therapy, the following can provide symptomatic relief:

• Topical anesthetics
• Sitz baths with warm water
• Oral analgesics
• Keeping lesions clean and dry 1

Treatment Selection Algorithm

1. Determine treatment approach:

   • Episodic therapy: For patients with infrequent recurrences
   • Suppressive therapy: For patients with ≥6 recurrences per year

2. For episodic therapy:

   • Prefer valacyclovir 500 mg twice daily for 3 days (convenient shorter course) 2
   • Alternative: valacyclovir 1000 mg once daily for 5 days (if once-daily dosing preferred) 3

3. For suppressive therapy:

   • <10 recurrences per year: valacyclovir 500 mg once daily 5, 6
   • ≥10 recurrences per year: valacyclovir 1000 mg once daily or 250 mg twice daily 5

4. For patients who prefer topical therapy or as adjunct:

   • Acyclovir cream 5% applied 5 times daily for 4 days 1

Patient Education Points

• Initiate treatment at the first sign of prodrome for maximum effectiveness
• Wash hands before and after applying topical medication
• Apply cream to cover all lesions completely
• Continue treatment for the full prescribed duration even if symptoms improve
• Abstain from sexual activity during outbreaks or prodromal symptoms
• Use condoms consistently to reduce transmission risk 1

Clinical Pearls

• Valacyclovir has higher bioavailability than acyclovir (10-20%), resulting in less frequent dosing 4, 2
• Once-daily valacyclovir regimens may improve patient compliance compared to multiple daily doses of acyclovir 6
• Topical therapy alone is less effective than oral therapy but can be used as an adjunct
• Food does not affect the absorption of acyclovir, so medications can be taken with or without food 4