Treatment of Herpes Simplex Virus Type 2 (HSV-2) in Adults
For adults with HSV-2 infection, the recommended treatment includes oral antiviral medications such as acyclovir, valacyclovir, or famciclovir, with specific regimens depending on whether it is a first episode, recurrent episode, or suppressive therapy. 1
First Episode Treatment
Recommended regimens for first-episode genital herpes include:
- Acyclovir 400 mg orally three times a day for 7-10 days, OR
- Acyclovir 200 mg orally five times a day for 7-10 days, OR
- Famciclovir 250 mg orally three times a day for 7-10 days, OR
- Valacyclovir 1 g orally twice a day for 7-10 days 1
Treatment may be extended if healing is incomplete after 10 days of therapy 1
For severe mucocutaneous HSV lesions requiring hospitalization, intravenous acyclovir is the first-line therapy until lesions begin to regress, then transition to oral therapy 1, 2
Recurrent Episodes Treatment
For recurrent episodes, episodic therapy options include:
Treatment should be initiated at the first sign of prodrome or genital lesions to maximize effectiveness 1
Short-course therapy (1-3 days) should not be used in patients with HIV infection 1
Suppressive Therapy
Suppressive therapy is recommended for persons who have frequent or severe recurrences (≥6 recurrences per year) 1, 5
Recommended suppressive regimens:
Suppressive therapy reduces recurrences by ≥75% and reduces asymptomatic viral shedding, which may decrease transmission risk 1, 6
After 1 year of continuous suppressive therapy, consider discontinuation to reassess recurrence frequency, as recurrences may decrease over time 1
Special Considerations
HIV-Infected Patients
- Higher doses and longer duration of treatment are recommended for HIV-infected patients 1
- Valacyclovir 500 mg twice daily is recommended for suppressive therapy in HIV-infected persons 1
- HIV-infected patients have higher rates of acyclovir-resistant HSV (approximately 6% vs 0.6% in immunocompetent individuals) 7
Pregnancy
- Acyclovir is the first choice for therapy of HSV infections in pregnancy due to its established safety profile 1
- Episodic therapy for first-episode HSV disease and recurrences can be offered during pregnancy 1
- Cesarean delivery is recommended for women with genital herpes prodrome or visible lesions at the onset of labor 1
Treatment Failure and Resistance
- Treatment failure should be suspected if lesions do not begin to resolve within 7-10 days after initiation of therapy 1
- For suspected acyclovir-resistant HSV, viral culture and susceptibility testing should be performed 1
- The treatment of choice for acyclovir-resistant HSV is IV foscarnet 1, 8
- Alternative options for resistant cases on external surfaces include topical trifluridine, cidofovir, or imiquimod 1, 8
Monitoring
- No laboratory monitoring is needed in patients receiving episodic or suppressive therapy unless they have substantial renal impairment 1
- For patients receiving high-dose IV acyclovir, monitoring of renal function is recommended at initiation of treatment and once or twice weekly during treatment 1
Patient Counseling
- Patients should be counseled about the natural history of HSV-2, potential for recurrent episodes, asymptomatic viral shedding, and sexual transmission 1
- Patients should abstain from sexual activity when lesions or prodromal symptoms are present 1
- Condom use during all sexual exposures with new or uninfected partners should be encouraged 1
- Suppressive therapy can reduce but does not eliminate the risk of transmission to partners 6
By following these treatment guidelines, clinicians can effectively manage HSV-2 infections in adults, reducing morbidity and improving quality of life for affected patients.