What is the recommended treatment for vaginal herpes?

Treatment for Vaginal Herpes

The recommended treatment for vaginal herpes includes acyclovir 400 mg orally three times daily for 7-10 days, valacyclovir 1 g orally twice daily for 7-10 days, or famciclovir 250 mg orally three times daily for 7-10 days for first clinical episodes, with shorter courses for recurrent episodes and daily suppressive therapy options for frequent recurrences. 1, 2

First Clinical Episode Treatment

• For initial genital herpes episodes, treatment should be initiated as soon as possible after symptom onset, ideally within 48-72 hours 1
• Recommended regimens include:
  • 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
  • Valacyclovir 1 g orally twice daily for 7-10 days 1, 3
• Treatment may be extended if healing is incomplete after 10 days 1

Recurrent Episodes Treatment

• Episodic therapy is most effective when started during the prodrome or within 1 day after onset of lesions 1, 2
• Recommended regimens for recurrent episodes:
  • Acyclovir 400 mg orally three times daily for 5 days 1, 2
  • Acyclovir 800 mg orally twice daily for 5 days 1, 2
  • Acyclovir 200 mg orally five times daily for 5 days 1, 2
  • Famciclovir 125 mg orally twice daily for 5 days 1, 2
  • Valacyclovir 500 mg orally twice daily for 5 days 1, 2, 3

Suppressive Therapy

• Daily suppressive therapy should be considered for patients with frequent recurrences (≥6 episodes per year) 1, 2
• Suppressive therapy reduces recurrence frequency by ≥75% and reduces asymptomatic viral shedding 1, 2
• Recommended regimens for suppressive therapy:
  • Acyclovir 400 mg orally twice daily 1, 2
  • Famciclovir 250 mg orally twice daily 1, 2
  • Valacyclovir 1 g orally once daily 1, 2, 3
  • Valacyclovir 500 mg orally once daily (for patients with <9 recurrences per year) 1, 2, 3
• For HIV-infected patients with CD4+ count ≥100 cells/mm³, valacyclovir 500 mg twice daily is recommended 3

Important Counseling Points

• Patients should be informed that genital herpes is a recurrent, incurable viral disease 1, 2
• Advise abstaining from sexual activity when lesions or prodromal symptoms are present 1, 2
• Encourage informing sex partners about having genital herpes 1, 2
• Recommend condom use during all sexual exposures with new or uninfected partners 1, 2
• Explain that asymptomatic viral shedding can occur, potentially leading to transmission even without symptoms 1, 2
• Explain the risk of neonatal infection to all patients, including men 1

Treatment Considerations and Pitfalls

• Topical acyclovir is substantially less effective than oral therapy and is not recommended 1, 4
• Valacyclovir is the only antiviral approved for once-daily suppressive therapy and for a 3-day regimen of episodic treatment 5
• After 1 year of continuous suppressive therapy, consider discontinuation to assess recurrence frequency 1, 2
• Safety and efficacy have been documented for acyclovir for up to 6 years, and for valacyclovir and famciclovir for 1 year 1
• Valacyclovir 500 mg once daily may be less effective for patients with very frequent recurrences (≥10 episodes per year) 1, 6

Special Populations

• For pregnant women, discuss the risk of neonatal herpes with healthcare providers during pregnancy 1
• For immunocompromised patients with severe disease, consider intravenous antiviral therapy 4
• For acyclovir-resistant cases, intravenous foscarnet or cidofovir may be used 4, 7