What is the recommended treatment for herpes simplex 2?

Treatment for Herpes Simplex 2 (Genital Herpes)

For genital herpes simplex 2 (HSV-2) infections, 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

Treatment Approach Based on Clinical Presentation

First Clinical Episode

• For first clinical episodes of genital herpes, longer treatment courses are recommended 1:
  • Valacyclovir 1 g orally twice daily for 7-10 days
  • Acyclovir 400 mg orally three times daily for 7-10 days
  • Acyclovir 200 mg orally five times daily for 7-10 days
  • Famciclovir 250 mg orally three times daily for 7-10 days
• Treatment may be extended if healing is incomplete after 10 days of therapy 1
• Severe mucocutaneous HSV lesions respond best to initial treatment with IV acyclovir 2

Recurrent Episodes

• For recurrent episodes, shorter courses are recommended 1, 3:
  • Valacyclovir 500 mg orally twice daily for 5 days
  • Acyclovir 400 mg orally three times daily for 5 days
  • Acyclovir 800 mg orally twice daily for 5 days
  • Acyclovir 200 mg orally five times daily for 5 days
  • Famciclovir 125 mg orally twice daily for 5 days
• Episodic therapy is most effective when started during the prodromal period or within 1 day after onset of lesions 1, 3
• Delayed treatment beyond 72 hours significantly reduces effectiveness 3
• Short-course therapy (1,2, or 3 days) should not be used in patients with HIV infection 2

Suppressive Therapy

• Daily suppressive therapy is recommended for patients with frequent recurrences (≥6 episodes per year) 1, 3:
  • Valacyclovir 1 g orally once daily or 500 mg orally once daily
  • Acyclovir 400 mg orally twice daily
  • Famciclovir 250 mg orally twice daily
• Suppressive therapy can reduce recurrence frequency by ≥75% and reduce asymptomatic viral shedding 1, 3
• After 1 year of suppressive therapy, consider discontinuation to assess recurrence frequency 3
• Valacyclovir suppressive therapy (500 mg once daily) has been shown to reduce HSV-2 transmission to susceptible heterosexual partners by 50% 4

Special Populations

HIV-Infected Patients

• HIV-infected patients with genital herpes should be monitored closely and 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 1
• Short-course therapy (1,2, or 3 days) should not be used in patients with HIV infection 2

Pregnant Women

• Safety considerations are important for pregnant women when selecting treatment 1
• Acyclovir, valacyclovir, and famciclovir should be used with caution during pregnancy, with appropriate risk-benefit assessment

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
• Treatment failure related to resistance should be suspected if lesions do not begin to resolve within 7-10 days after initiation of therapy 2
• For acyclovir-resistant HSV, IV foscarnet is the treatment of choice 2, 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, 3
• The median time to lesion healing with valacyclovir 500 mg is 4 days versus 6 days with placebo 5
• Consistent condom use should be encouraged to reduce HSV-2 transmission 1
• Patients should be counseled to abstain from sexual activity when lesions or prodromal symptoms are present 1
• Laboratory confirmation is important for diagnosis, especially in HIV-seropositive patients 2

Monitoring and Adverse Events

• Acyclovir, valacyclovir, and famciclovir are occasionally associated with nausea or headache 2
• No laboratory monitoring is needed in patients receiving episodic or suppressive therapy unless the patient has substantial renal impairment 2
• For patients receiving high-dose IV acyclovir, monitoring of renal function and dose adjustment as necessary are recommended at initiation of treatment and once or twice weekly for the duration of treatment 2