What is the recommended treatment for a genital herpes flare-up?

Treatment for Genital Herpes Flare-Up

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

First-Line Antiviral Options

The CDC recommends the following antiviral medications for treating recurrent genital herpes episodes:

• Valacyclovir: 500 mg twice daily for 5-10 days 2
  • FDA-approved 3-day regimen: 500 mg twice daily 1
• Famciclovir: 125 mg twice daily for 5 days 2
• Acyclovir: 400 mg three times daily for 5-10 days 2

Valacyclovir's 3-day regimen has been shown to be as effective as the 5-day course for recurrent episodes, with median time to lesion healing of 4.4 days versus 4.7 days, respectively 3. The shorter course may improve treatment adherence.

Treatment Timing and Efficacy

• Initiate treatment at the earliest sign or symptom (tingling, itching, or burning) 1
• Treatment is most effective when started within 24 hours of symptom onset 1
• Antiviral therapy reduces:
  • Duration of lesions
  • Pain duration
  • Viral shedding
  • Risk of transmission

Dosing Considerations

• For patients with normal renal function: Standard dosing as above
• For patients with frequent recurrences (≥10 per year): Consider suppressive therapy with valacyclovir 1 gram once daily 1, 4
• For patients with fewer recurrences (<10 per year): Valacyclovir 500 mg once daily is effective for suppression 4

Special Populations

• HIV-infected patients:

  • May require longer courses of therapy
  • For suppressive therapy: Valacyclovir 500 mg twice daily 2
  • More aggressive suppressive therapy may be required due to frequent recurrences 2

• Pregnant patients:

  • Acyclovir has an established safety profile during pregnancy 2
  • Consider suppressive therapy starting at 36 weeks gestation to reduce risk of outbreak during delivery 5

Preventing Transmission

• Avoid direct contact with active lesions 2
• Use latex condoms during sexual activity 2
• Consider daily suppressive antiviral therapy for those with frequent recurrences 2
• Avoid sexual contact during outbreaks 5

Common Pitfalls to Avoid

1. Delayed treatment initiation: Starting therapy more than 24-48 hours after symptom onset significantly reduces effectiveness

2. Inadequate pain management: For painful lesions, consider adding acetaminophen or NSAIDs 2

3. Failure to recognize treatment-resistant cases: If lesions persist despite appropriate therapy, consider:

   • Medication adherence issues
   • Potential acyclovir resistance (especially in immunocompromised patients)
   • Alternative diagnoses

4. Not addressing psychological impact: Genital herpes can cause significant psychological distress that may require additional support

Follow-up Recommendations

• Re-examine 3-7 days after treatment initiation to assess response 2
• Monitor for complete resolution of lesions 2
• Evaluate for potential complications 2

Valacyclovir's once or twice daily dosing makes it an attractive option compared to acyclovir's five-times-daily regimen, potentially improving treatment adherence 6.