What is the treatment for herpes?

Treatment for Herpes

The preferred treatment for herpes includes antiviral medications such as acyclovir, valacyclovir, or famciclovir, which can be administered as episodic therapy for outbreaks or as daily suppressive therapy to prevent recurrences and reduce transmission risk. 1, 2

Types of Treatment Approaches

Episodic Therapy

• First-episode genital herpes:

  • Acyclovir 400 mg orally three times daily for 7-10 days
  • Acyclovir 200 mg orally five times daily for 7-10 days
  • Famciclovir 250 mg orally three times daily for 7-10 days
  • Valacyclovir 1 gram twice daily for 10 days 1, 2

• Recurrent episodes:

  • Valacyclovir 500 mg twice daily for 3 days (equivalent efficacy to 5-day course) 1, 3
  • Acyclovir 800 mg three times daily for 2 days 4
  • Start treatment at first sign of prodrome or within 1 day of lesion onset for maximum effectiveness 2

Suppressive Therapy

• For frequent recurrences or to prevent transmission:
  • Valacyclovir 1 gram once daily 5
  • Acyclovir 400 mg twice daily 2
  • Famciclovir (dosage varies) 2

Treatment Selection Algorithm

1. Determine type of infection:

   • First episode vs. recurrent
   • HSV-1 vs. HSV-2 (same medication dosages recommended for both) 1

2. Assess frequency and severity:

   • For infrequent outbreaks: Episodic therapy
   • For frequent outbreaks (≥6 per year): Consider suppressive therapy 1, 5
   • For severe symptoms: Higher doses may be needed

3. Consider patient factors:

   • Renal function (dose adjustments required)
   • HIV status (may require higher doses)
   • Pregnancy status
   • Medication adherence capabilities 2

Special Populations

Immunocompromised Patients

• Higher doses and longer treatment durations recommended
• Continue treatment until complete healing of lesions 2

HIV-Infected Patients

• Higher oral doses (400 mg orally 3-5 times daily) may be necessary
• For suppressive therapy in HIV+ patients: Valacyclovir 500 mg twice daily 2, 5

Children

• For children under 45 kg: Acyclovir 20 mg/kg body weight (maximum 800 mg/dose) orally 4 times daily for 7-10 days 2

Dose Adjustments for 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
[2]

Symptomatic Relief

• Topical anesthetics
• Sitz baths with warm water
• Oral analgesics
• Keep lesions clean and dry 2

Important Clinical Considerations

Transmission Prevention

• Abstain from sexual activity when lesions or prodromal symptoms are present
• Use condoms consistently during all sexual encounters
• Inform sexual partners about HSV status
• Daily suppressive therapy reduces but does not eliminate transmission risk 1, 2

Treatment Efficacy

• Median time to lesion healing with valacyclovir: 4-5 days vs. 6 days with placebo 5
• Median time to cessation of pain: 2.5-3 days with treatment vs. 4 days with placebo 5, 3
• Median time to cessation of viral shedding: 2 days with treatment vs. 4 days with placebo 5

Common Pitfalls

1. Delayed treatment initiation: Provide patients with prescription to keep on hand for immediate treatment at first sign of prodrome 2
2. Inadequate counseling: Discuss natural history of infection, recurrence potential, and transmission risk 2
3. Failure to consider suppressive therapy: All patients with recurrent HSV-2 should be offered suppressive therapy option 1
4. Overlooking asymptomatic shedding: Transmission can occur even without visible lesions 2

Acyclovir-Resistant Herpes

For cases of acyclovir-resistant HSV, alternative treatments may include:

• Brincidofovir
• Imiquimod
• Topical cidofovir 1

While topical acyclovir has shown some efficacy in clinical trials 6, systemic therapy is generally preferred for genital herpes due to superior efficacy and convenience 7, 8.