What is the recommended treatment for Herpes Simplex Virus 2 (HSV 2)?

Treatment of Herpes Simplex Virus 2 (HSV-2)

For HSV-2 infections, oral antiviral therapy with valacyclovir, famciclovir, or acyclovir is the recommended treatment, with specific regimens depending on whether it's a first episode, recurrent episode, or suppressive therapy. 1, 2

First Clinical Episode Treatment

• First episodes of genital HSV-2 should be treated with oral antivirals for 7-10 days or until clinical resolution 1
• Recommended regimens include:
  • Acyclovir 400 mg orally three times daily for 7-10 days 1, 3
  • Acyclovir 200 mg orally five times daily for 7-10 days 3
  • Valacyclovir 1 g orally twice daily for 7-10 days 3
  • Famciclovir 250 mg orally three times daily for 7-10 days 3
• For severe disease requiring hospitalization, acyclovir 5-10 mg/kg IV every 8 hours is recommended until clinical improvement, then switch to oral therapy 1, 3

Episodic Treatment for Recurrent Episodes

• Treatment should be initiated at the first sign of recurrence (prodrome or within 1 day of lesion onset) 2
• Recommended regimens for episodic therapy include:
  • Valacyclovir 500 mg orally twice daily for 5 days 1, 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
• Short-course therapy (1-3 days) should not be used in patients with HIV infection 1
• Episodic therapy reduces the duration of lesions, viral shedding, and pain 4, 5

Suppressive Therapy

• Daily suppressive therapy is recommended for patients with frequent recurrences (≥6 episodes per year) 1, 2, 3
• Recommended regimens for suppressive therapy include:
  • Valacyclovir 1 g orally once daily 2, 3, 4
  • Valacyclovir 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 reduces recurrence frequency by ≥75% 2, 3
• Suppressive therapy with valacyclovir reduces the risk of HSV-2 transmission to susceptible heterosexual partners by 48% overall and symptomatic transmission by 75% 4, 6, 7
• After 1 year of suppressive therapy, consider discontinuation to reassess recurrence frequency 2

Special Considerations

• For immunocompromised patients, higher doses and longer treatment durations may be necessary 8, 3
• Topical acyclovir is substantially less effective than oral therapy and is not recommended 2, 3
• Antiviral resistance is rare in immunocompetent patients but more common in immunocompromised individuals 3
• For acyclovir-resistant HSV, IV foscarnet is the treatment of choice 1
• Newer agents such as helicase-primase inhibitors are in development for treatment of HSV infections, including resistant strains 1, 9

Patient Education and Counseling

• Patients should be informed that genital herpes is a recurrent, incurable viral disease 2
• Antiviral medications control symptoms but do not eradicate the virus or prevent all recurrences 2, 4
• Patients should abstain from sexual activity when lesions or prodromal symptoms are present 2, 3
• Asymptomatic viral shedding can occur, potentially leading to transmission even without symptoms 2, 4
• Consistent condom use and disclosure of HSV-2 status to partners are recommended to reduce transmission risk 1
• Suppressive therapy in combination with safer sex practices provides the best protection against transmission 4, 7

Treatment Pitfalls to Avoid

• Delaying treatment beyond 72 hours significantly reduces effectiveness 8
• Using topical therapy alone has poor efficacy compared to systemic treatment 8, 3
• Failing to consider suppressive therapy in patients with frequent recurrences 2, 3
• Using short-course therapy in immunocompromised patients 1
• Not recognizing potential acyclovir resistance in treatment failure cases (lesions not beginning to resolve within 7-10 days of treatment) 1