What is the recommended treatment for genital herpes simplex?

Treatment of Genital Herpes Simplex

The recommended first-line treatment for genital herpes simplex is oral antiviral therapy with valacyclovir, acyclovir, or famciclovir, with specific regimens depending on whether it is a first clinical episode or recurrent infection. 1, 2

First Clinical Episode Treatment

• Recommended regimens (7-10 days):

  • Valacyclovir 1 g orally twice daily 1, 3
  • Acyclovir 400 mg orally three times daily 1
  • Acyclovir 200 mg orally five times daily 1
  • Famciclovir 250 mg orally three times daily 1

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

• Clinical trials have demonstrated that valacyclovir (1 g twice daily) is as effective as acyclovir (200 mg five times daily) for first episodes, with the advantage of less frequent dosing 4

Recurrent Episodes Treatment

• Recommended regimens (5 days):

  • Valacyclovir 500 mg orally twice daily 2
  • Acyclovir 400 mg orally three times daily 2
  • Acyclovir 800 mg orally twice daily 2
  • Acyclovir 200 mg orally five times daily 2
  • Famciclovir 125 mg orally twice daily 2

• Episodic therapy is most effective when started during the prodrome or within 1 day after onset of lesions 2

• A shorter 2-day course of acyclovir (800 mg three times daily) has been shown to significantly reduce the duration of lesions, episode length, and viral shedding compared to placebo 5

Suppressive Therapy

• For patients with frequent recurrences (≥6 episodes per year):

  • Valacyclovir 1 g orally once daily 2, 6
  • Valacyclovir 500 mg orally once daily (for patients with <10 recurrences per year) 2, 6
  • Acyclovir 400 mg orally twice daily 2, 7
  • Famciclovir 250 mg orally twice daily 2, 7

• Suppressive therapy can reduce the frequency of recurrences by ≥75% and reduce asymptomatic viral shedding 2

• Valacyclovir is the only antiviral drug approved for once-daily dosing for suppressive therapy 8

Important Counseling Points

• Genital herpes is a recurrent, incurable viral disease; antiviral medications control symptoms but do not eradicate the virus 1, 2

• Patients should abstain from sexual activity when lesions or prodromal symptoms are present 1, 2

• Sexual transmission can occur during asymptomatic periods due to viral shedding 1, 2

• Patients should inform sex partners about having genital herpes and use condoms during all sexual exposures with new or uninfected partners 1, 2

Special Considerations

• For immunocompromised patients with severe disease, intravenous acyclovir may be indicated 9

• Topical acyclovir therapy is substantially less effective than systemic therapy and is not recommended 1

• After 1 year of suppressive therapy, consider discontinuation to reassess recurrence frequency 2

Clinical Pearls and Pitfalls

• Valacyclovir and famciclovir offer improved oral bioavailability and more convenient dosing schedules compared to acyclovir, but may be more expensive 7

• For patients with >10 recurrences per year, higher doses of suppressive therapy (valacyclovir 1 g daily, valacyclovir 250 mg twice daily, or acyclovir 400 mg twice daily) are more effective 6

• Patients should be educated about the natural history of genital herpes, with emphasis on potential recurrences, asymptomatic viral shedding, and sexual transmission 1