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

Treatment Options for Recurrent Genital Herpes

For recurrent genital herpes, the recommended treatments are valacyclovir 500 mg twice daily or 1000 mg once daily for 5 days, acyclovir 800 mg three times daily for 2 days, or famciclovir 1000 mg twice daily for 1 day for episodic treatment, with valacyclovir 1000 mg daily or acyclovir 400 mg twice daily for suppressive therapy in patients with frequent recurrences. 1

Oral Antiviral Medications

Episodic Treatment Options

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

• Valacyclovir:

  • 500 mg twice daily for 5 days 1, 2
  • 1000 mg once daily for 5 days (equivalent efficacy to twice-daily dosing) 2
  • Better bioavailability than acyclovir (10-20%) 3, 4
  • Less frequent dosing improves patient adherence 4

• Acyclovir:

  • 800 mg three times daily for 2 days 1
  • 400 mg three times daily for 5 days 1
  • Should be taken with or without food (no effect on absorption) 3

• Famciclovir:

  • 1000 mg twice daily for 1 day 1
  • Comparable efficacy to valacyclovir 4

Suppressive Treatment Options

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

• Valacyclovir:

  • 500 mg once daily (for patients with <10 recurrences per year) 5
  • 1000 mg once daily (for patients with ≥10 recurrences per year) 5, 6
  • Only antiviral approved for once-daily suppressive therapy 4
  • 81-91% of patients remain recurrence-free during quarterly assessments 6

• Acyclovir:

  • 400 mg twice daily 5, 7
  • Reduces monthly recurrence rate from 1.4 to 0.05 7

Topical Treatment Options

• Acyclovir cream 5%:
  • Apply 5 times daily for 4 days 1
  • Most effective when started during prodrome or early lesion stage 1
  • Should be applied to cover all lesions completely 1

Symptomatic Relief Measures

• Topical options:

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

• Systemic options:

  • Oral analgesics for pain management 1
  • Follow WHO pain management ladder for moderate to severe pain 1

Special Considerations

Renal Impairment

Dose adjustments are necessary for patients with reduced renal function:

• Valacyclovir:

  • 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

• Acyclovir (for recurrent genital herpes):

  • CrCl ≥50 mL/min: 500 mg every 12 hours
  • CrCl 30-49 mL/min: No reduction
  • CrCl 10-29 mL/min: 500 mg every 24 hours
  • CrCl <10 mL/min: 500 mg every 24 hours 1

HIV-Infected Patients

Higher doses may be necessary:

• Acyclovir 400 mg orally 3-5 times daily 1
• For suppressive therapy in HIV patients: Acyclovir 500 mg every 12 hours (with normal renal function) 1

Patient Education and Counseling

• Instruct patients to:
  • Apply medication at the first sign of prodrome 1
  • Wash hands before and after application 1
  • Complete the full course of treatment even if symptoms improve 1
  • Abstain from sexual activity during outbreaks or prodromal symptoms 1
  • Use condoms consistently to reduce transmission risk 1
  • Be aware of asymptomatic viral shedding and transmission risk 1

Common Pitfalls and Caveats

• Delayed treatment initiation: Treatment is most effective when started within the first 24 hours of symptoms
• Inadequate dosing: Ensure proper dosing based on frequency of recurrences and renal function
• Poor adherence: Once-daily valacyclovir may improve compliance compared to multiple daily doses 4, 6
• Failure to adjust for renal impairment: Dose adjustments are essential to prevent toxicity in patients with reduced renal function 1, 3
• Discontinuation of suppressive therapy: Recurrences typically return to pre-treatment frequency after stopping suppressive therapy 5, 7