What is the treatment for Herpes simplex 2?

Treatment for Herpes Simplex 2 (Genital Herpes)

For genital herpes simplex 2 (HSV-2) infection, oral antiviral medications including valacyclovir, acyclovir, and famciclovir are the mainstay of treatment, with valacyclovir 500 mg twice daily for 5 days being the preferred first-line therapy for recurrent episodes due to its convenient dosing and effectiveness in reducing symptoms and viral shedding. 1, 2

First Clinical Episode Treatment

• For first clinical episodes of genital herpes, longer treatment courses are recommended 1:

  • Valacyclovir 1 g orally twice daily for 7-10 days 1, 2
  • Acyclovir 400 mg orally three times daily for 7-10 days 1
  • Acyclovir 200 mg orally five times daily for 7-10 days 1
  • Famciclovir 250 mg orally three times daily for 7-10 days 1

• Treatment may be extended if healing is incomplete after 10 days of therapy 1

Recurrent Episodes Treatment

• For recurrent episodes, shorter courses are effective 2, 3:

  • Valacyclovir 500 mg orally twice daily for 5 days (preferred regimen) 2, 3
  • Acyclovir 400 mg orally three times daily for 5 days 2, 3
  • Acyclovir 800 mg orally twice daily for 5 days 2, 3
  • Acyclovir 200 mg orally five times daily for 5 days 2, 3
  • Famciclovir 125 mg orally twice daily for 5 days 2, 3

• Episodic therapy is most effective when started during the prodromal period or within 1 day after onset of lesions 2, 3

• Delayed treatment beyond 72 hours significantly reduces effectiveness 2

Suppressive Therapy

• Daily suppressive therapy should be considered for patients with frequent recurrences (≥6 episodes per year) 1, 2, 3:

  • Valacyclovir 1 g orally once daily or 500 mg orally once daily 2, 3
  • Acyclovir 400 mg orally twice daily 2, 3
  • Famciclovir 250 mg orally twice daily 2, 3

• Suppressive therapy can reduce recurrence frequency by ≥75% and reduce asymptomatic viral shedding 2, 3

• Valacyclovir appears to be somewhat better than famciclovir for suppression of genital herpes and associated viral shedding 4

• After 1 year of suppressive therapy, consider discontinuation to assess recurrence frequency 3

Special Populations

HIV-Infected Patients

• HIV-infected patients with genital herpes should be monitored closely 1
• May require longer courses of therapy than those recommended for HIV-negative patients 1
• Famciclovir 500 mg twice daily has been effective in reducing recurrences and subclinical shedding in HIV-infected patients 5

Pregnant Women

• Safety considerations are important for pregnant women 1
• Ciprofloxacin is contraindicated during pregnancy 1

Important Clinical Considerations

• Topical acyclovir is substantially less effective than systemic 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 1
• Dosing strategies that are most feasible for patient adherence should be prioritized 1
• The same medication dosages and frequencies are recommended for genital HSV-1 infection as for HSV-2 1

Common Side Effects

• Most common side effects of oral antivirals include headache and nausea 6, 7
• For valacyclovir, headache (13-35%) and nausea (6-11%) are most commonly reported 6
• For acyclovir, nausea/vomiting (2.7%) and diarrhea (2.4%) are most commonly reported 7

Transmission Prevention

• Suppressive therapy can reduce the risk of transmission to sexual partners 1, 3
• Patients should be counseled to abstain from sexual activity when lesions or prodromal symptoms are present 3
• Consistent condom use should be encouraged to reduce HSV-2 transmission 1

Treatment Failure Considerations

• If symptoms persist beyond expected healing time, consider 1:

  • Incorrect diagnosis
  • Co-infection with another STD
  • HIV infection
  • Poor medication adherence
  • Antiviral resistance

• For acyclovir-resistant HSV, IV foscarnet is the treatment of choice 1