What is the recommended treatment for a genital herpes outbreak?

Treatment of Genital Herpes Outbreaks

For recurrent genital herpes outbreaks, valacyclovir 500 mg twice daily for 3 days is the recommended first-line treatment, initiated at the first sign or symptom of an episode. 1

First-Line Antiviral Options

Valacyclovir

• Initial episode: 1 gram twice daily for 10 days 1
• Recurrent episodes:
  • 500 mg twice daily for 3 days (preferred regimen) 1
  • Alternative: 1 gram twice daily for 1 day 1
• Suppressive therapy:
  • 1 gram once daily for patients with normal immune function 1
  • 500 mg once daily for patients with ≤9 recurrences per year 1
  • 500 mg twice daily for HIV-infected patients with CD4+ count ≥100 cells/mm³ 1

Famciclovir

• Recurrent episodes: 1000 mg twice daily for 1 day 2
• Suppressive therapy: 250 mg twice daily 2
• For HIV-infected patients: 500 mg twice daily for 7 days 2

Acyclovir

• Recurrent episodes: 800 mg three times daily for 2 days 3
• Suppressive therapy: 400 mg twice daily 1

Treatment Timing and Efficacy

Treatment efficacy is maximized when started at the earliest symptoms (tingling, itching, burning) or within the first 48 hours of lesion onset 4, 1. Initiating therapy within 72 hours of rash onset significantly reduces:

• Time to last new lesion formation
• Loss of vesicles
• Full crusting
• Pain during treatment 4

The median time to lesion healing with valacyclovir 500 mg twice daily is 4 days versus 6 days with placebo 1. Treatment also reduces viral shedding duration from 4 days to 2 days 1.

Special Populations

Renal Impairment

Dosage adjustment is required based on creatinine clearance:

Valacyclovir adjustment:

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
[4]

HIV-Infected Patients

• Higher doses may be required, especially with CD4+ counts <200 cells/μL 4
• Valacyclovir: 500 mg twice daily for suppressive therapy 1
• Famciclovir: 500 mg twice daily for 7 days for recurrent episodes 2

Symptom Management

In addition to antiviral therapy, symptom management is important:

• Mild pain: Acetaminophen or NSAIDs 4
• Localized pain: Topical options such as lidocaine patches or capsaicin cream 4
• Comfort measures:
  • Sitz baths with warm water
  • Keeping lesions clean and dry
  • Wearing loose-fitting clothing 4

Prevention and Patient Education

1. Abstain from sexual activity while lesions are present 4
2. Use condoms during all sexual exposures 4
3. Inform patients about the potential for recurrent episodes and asymptomatic transmission 4
4. Women of childbearing age should inform healthcare providers during pregnancy 4
5. Suppressive therapy reduces:
   • Frequency of recurrences by 70-80%
   • Severity and duration of breakthrough episodes
   • Asymptomatic viral shedding 4
   • Risk of transmission to uninfected partners 5

Common Pitfalls to Avoid

1. Delayed treatment: Decreases efficacy; start at earliest symptoms 4
2. Underdosing: Can lead to treatment failure 4
3. Premature discontinuation: Can lead to recurrence or prolonged symptoms 4
4. Missing underlying causes: Consider HIV testing if recurrent or rapidly recurring episodes 4
5. Inadequate pain control: Address concurrently with antiviral therapy 4

The choice between valacyclovir, famciclovir, and acyclovir often depends on cost, convenience of dosing schedule, and patient preference, with valacyclovir offering the advantage of less frequent dosing 6, 7.