What is the recommended treatment for a genital herpes flare?

Treatment for Genital Herpes Flare

The recommended treatment for a genital herpes flare is valacyclovir 500 mg twice daily for 3 days, initiated at the first sign or symptom of an episode. 1

First-Line Treatment Options

For recurrent genital herpes episodes, the following antiviral medications are effective:

1. Valacyclovir (preferred):

   • 500 mg twice daily for 3 days 1
   • Start at the earliest symptom (tingling, itching, burning)
   • Offers the advantage of less frequent dosing compared to acyclovir

2. Acyclovir alternatives:

   • 400 mg orally 3-5 times daily until clinical resolution 2
   • 800 mg orally three times daily for 2 days

3. For severe cases requiring hospitalization:

   • Acyclovir 5-10 mg/kg IV every 8 hours for 5-7 days 2

Treatment Selection Considerations

The choice between treatment options should be based on:

• Severity of symptoms: For mild to moderate outbreaks, oral therapy is sufficient; severe cases may require IV treatment
• Patient preference: Valacyclovir's less frequent dosing (twice daily) may improve adherence compared to acyclovir's 5-times-daily regimen 3
• Previous response: Consider what has worked well for the patient in past episodes
• Renal function: Dose adjustments required for impaired renal function 2

Dosage Adjustments for Renal Impairment

For patients with renal impairment, adjust dosing based on creatinine clearance 2:

Creatinine Clearance (mL/min)	Valacyclovir Adjustment	Acyclovir Adjustment (800 mg)
>25	Standard dosing	800 mg every 4 hours, 5x/day
10-25	50% of standard dose	800 mg every 8 hours
0-10	50% of standard dose every 24h	800 mg every 12 hours

Suppressive Therapy

For patients with frequent recurrences (≥6 per year), consider suppressive therapy:

• Valacyclovir: 1 gram once daily; for patients with <9 recurrences per year, 500 mg once daily is effective 1, 4
• Acyclovir: 400 mg twice daily 4

Suppressive therapy not only reduces recurrences but also decreases asymptomatic viral shedding and transmission risk 1.

Patient Education and Follow-up

• Advise abstaining from sexual activity while lesions are present 2
• Educate about asymptomatic viral shedding and transmission risk 2
• Encourage consistent condom use during all sexual exposures 2
• Re-examine 3-7 days after treatment initiation to assess response 2
• If no improvement occurs, consider alternative diagnoses, co-infection with other STIs, or antiviral resistance 2

Pain Management

For associated pain:

• Mild pain: Acetaminophen or NSAIDs 2
• Moderate to severe pain: Consider gabapentin, pregabalin, or tricyclic antidepressants 2

Special Considerations

• HIV-infected patients: May require longer treatment courses; valacyclovir 500 mg twice daily for suppressive therapy 1
• Pregnant patients: Acyclovir has an established safety profile 2
• Acyclovir-resistant strains: Consider hospitalization and foscarnet 40 mg/kg IV every 8 hours 2

The 3-day valacyclovir regimen (500 mg twice daily) has been shown to be equally effective as the 5-day regimen, with comparable median times to lesion healing (4.4 vs. 4.7 days) and pain duration (2.9 vs. 2.5 days) 5, making it a convenient and effective option for most patients with recurrent genital herpes.