What treatment is recommended for a 20-year-old female with recurrent Herpes Simplex Virus (HSV) infection, who was initially prescribed Valtrex (valacyclovir) 2 weeks ago, but has since experienced a recurrence of symptoms, including pelvic pain, discharge, and sores?

Treatment for Recurrent Genital Herpes in a 20-Year-Old Female

For this patient with recurrent genital herpes who has completed initial treatment but is experiencing a recurrence with pelvic pain, discharge, and sores, episodic antiviral therapy with valacyclovir 500 mg orally twice daily for 5 days is the recommended treatment.

Initial Assessment

• Recurrent episodes of genital herpes are common after initial infection, particularly with HSV-2 1
• The patient's presentation (sores returning after initial treatment) is consistent with a recurrent episode of genital herpes 1
• The presence of pelvic pain and discharge suggests possible concurrent inflammation or infection that should be evaluated 1

Treatment Options for Recurrent Episodes

Recommended Episodic Treatment Regimens:

• Valacyclovir 500 mg orally twice daily for 5 days (recommended for this patient) 1, 2
• Acyclovir 400 mg orally three times daily for 5 days 1
• Acyclovir 800 mg orally twice daily for 5 days 1
• Acyclovir 200 mg orally five times daily for 5 days 1
• Famciclovir 125 mg orally twice daily for 5 days 1

Treatment Considerations:

• Episodic therapy is most effective when started during the prodrome or within 1 day after onset of lesions 1
• The FDA label for valacyclovir (Valtrex) indicates that treatment efficacy for recurrent episodes is not established when initiated more than 24 hours after onset of signs and symptoms 2
• Treatment should be initiated as early as possible for optimal effectiveness 3

Patient Education and Counseling

• Advise the patient that genital herpes is a recurrent, incurable viral disease 1
• Explain that antiviral medications can control symptoms but do not eradicate the virus or prevent all recurrences 1, 2
• Counsel the patient to:
  • Abstain from sexual activity when lesions or prodromal symptoms are present 1
  • Inform sex partners about having genital herpes 1
  • Use condoms during all sexual exposures with new or uninfected partners 1
  • Be aware that asymptomatic viral shedding can occur, potentially leading to transmission 1, 4

Considerations for Long-term Management

If the patient experiences frequent recurrences (≥6 episodes per year), daily suppressive therapy should be considered:

• Valacyclovir 1 g orally once daily 1, 4
• Valacyclovir 500 mg orally once daily (less effective if ≥10 episodes per year) 1, 4
• Acyclovir 400 mg orally twice daily 1
• Famciclovir 250 mg orally twice daily 1

Benefits of Suppressive Therapy:

• Reduces frequency of recurrences by ≥75% 1, 4
• Safety documented for up to 6 years with acyclovir and 1 year with valacyclovir 1
• Reduces but does not eliminate asymptomatic viral shedding 1, 4
• Valacyclovir appears somewhat more effective than famciclovir for suppression 5

Follow-up Recommendations

• If symptoms persist beyond 5 days of treatment, consider extending treatment 1
• Evaluate for potential co-infections if discharge and pelvic pain persist 1
• After 1 year of suppressive therapy (if initiated), consider discontinuation to assess recurrence frequency 1
• Discuss psychological adjustment to having genital herpes 1

Common Pitfalls to Avoid

• Delaying treatment beyond 24 hours after symptom onset reduces effectiveness 2
• Using topical therapy alone has poor efficacy compared to systemic treatment 1
• Failing to consider suppressive therapy in patients with frequent recurrences 1
• Not providing adequate counseling about transmission risk and prevention 1