Treatment for Recurrent Genital Herpes Outbreaks
For recurrent genital herpes outbreaks, episodic antiviral therapy with valacyclovir 500 mg orally twice daily for 3 days is the recommended first-line treatment, which should be initiated at the first sign of prodrome or lesions to maximize effectiveness. 1, 2
Episodic Treatment Options
- Valacyclovir 500 mg orally twice daily for 3 days is FDA-approved and most effective when started within 24 hours of symptom onset 1, 2
- Alternative regimens include:
Episodic therapy is most effective when initiated during the prodromal phase or within 1 day after lesion onset, significantly shortening the duration of lesions, pain, and viral shedding 1, 2.
Suppressive Therapy Considerations
For patients with frequent recurrences (≥6 episodes per year), daily suppressive therapy should be considered:
- Valacyclovir 1 gram orally once daily (or 500 mg once daily for patients with ≤9 recurrences per year) 1, 2
- Acyclovir 400 mg orally twice daily 1
- Famciclovir 250 mg orally twice daily 1, 3
Suppressive therapy reduces recurrence frequency by ≥75% and decreases asymptomatic viral shedding, which may reduce transmission risk 1, 4. Clinical studies have demonstrated safety with long-term use—up to 6 years with acyclovir and 1 year with valacyclovir 1.
Patient Education and Counseling
- Advise patients that genital herpes is a recurrent, incurable viral disease; antivirals control symptoms but don't eradicate the virus 1
- Recommend abstaining from sexual activity when lesions or prodromal symptoms are present 1
- Encourage informing sexual partners about having genital herpes and using condoms during all sexual exposures 1
- Explain that asymptomatic viral shedding can occur, potentially leading to transmission even without visible lesions 1
Follow-up Recommendations
- After 1 year of suppressive therapy, consider discontinuation to reassess recurrence frequency 1
- For persistent symptoms beyond 5 days of treatment, consider extended treatment course and evaluate for potential co-infections 1
- For patients with HIV or immunocompromise, higher doses or longer duration of therapy may be needed 1
Clinical Pearls and Pitfalls
- Topical acyclovir is substantially less effective than oral therapy and is not recommended 5
- Valacyclovir is the only antiviral approved for a 3-day regimen of episodic treatment for recurrent genital herpes, offering improved convenience and potentially better adherence 6
- Treatment should be initiated as early as possible for optimal effectiveness 1, 2
- For patients with very frequent recurrences (≥10 per year), higher doses of suppressive therapy may be more effective 4