What is the treatment for a herpes simplex virus (HSV) breakout in the genital region?

Treatment for Genital Herpes Simplex Virus Outbreaks

For recurrent genital herpes outbreaks, episodic antiviral therapy with valacyclovir 500 mg orally twice daily for 5 days is the recommended first-line treatment, which should be started during the prodrome or within 1 day of lesion onset for maximum effectiveness. 1

First-Line Treatment Options for Recurrent Genital Herpes

• Valacyclovir 500 mg orally twice daily for 5 days is recommended by the CDC as first-line therapy for recurrent genital herpes outbreaks 1
• Alternative regimens include:
  • 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

Timing of Treatment

• Episodic therapy is most effective when started during the prodromal period or within 1 day after onset of lesions 1
• Early treatment can reduce the duration of symptoms and may abort the episode in some patients 2
• Delayed treatment beyond 72 hours significantly reduces effectiveness 3

Treatment Efficacy

• Valacyclovir has similar efficacy to acyclovir in episodic treatment of genital herpes but offers more convenient dosing 4
• Median time to healing with famciclovir is 4.3 days compared to 6.1 days with placebo 5
• Valacyclovir can reduce the median time to lesion healing from 6 days to 4 days 6
• A 2-day course of acyclovir (800 mg three times daily) has been shown to significantly reduce the duration of lesions, episode, and viral shedding compared to placebo 7

Suppressive Therapy Considerations

• Daily suppressive therapy should be considered for patients with frequent recurrences (≥6 episodes per year) 1
• Recommended suppressive regimens include:
  • Valacyclovir 1 g orally once daily or 500 mg orally once daily 1
  • Acyclovir 400 mg orally twice daily 1
  • Famciclovir 250 mg orally twice daily 1
• Suppressive therapy can reduce recurrence frequency by ≥75% and reduce asymptomatic viral shedding 1
• Suppressive therapy with valacyclovir is the only antiviral approved for once-daily dosing 4

Important Clinical Considerations

• Topical acyclovir is substantially less effective than oral therapy and is not recommended 1, 3
• Systemic antiviral drugs partially control symptoms but do not eradicate latent virus or affect subsequent recurrences after discontinuation 8
• After 1 year of suppressive therapy, consider discontinuation to assess recurrence frequency 1
• For patients with persistent symptoms beyond 5 days of treatment, consider extended treatment and evaluate for potential co-infections 1

Patient Education and Counseling

• Patients should be counseled that genital herpes is a recurrent, incurable viral disease 1
• Advise patients to abstain from sexual activity when lesions or prodromal symptoms are present 1
• Inform patients that asymptomatic viral shedding can occur, potentially leading to transmission 1
• Encourage patients to inform sex partners about having genital herpes and to use condoms during all sexual exposures with new or uninfected partners 1

Special Populations

• For immunocompromised patients, including those with HIV, higher doses or longer courses of antivirals may be needed 8
• HIV-infected patients who have genital herpes should be monitored closely as they may require longer courses of therapy 8
• For pregnant women, the safety of various treatments should be considered - ciprofloxacin is contraindicated during pregnancy 8