What are the treatment guidelines for vaginal herpes simplex?

Treatment Guidelines for Vaginal Herpes Simplex

For vaginal herpes simplex infections, antiviral therapy is the cornerstone of treatment, with specific regimens recommended based on whether it is a first clinical episode or recurrent infection. 1, 2

First Clinical Episode Treatment

• Recommended antiviral regimens for first episodes include:

  • Acyclovir 400 mg orally three times daily for 7-10 days 3
  • Acyclovir 200 mg orally five times daily for 7-10 days 3
  • Famciclovir 250 mg orally three times daily for 7-10 days 3
  • Valacyclovir 1 g orally twice daily for 7-10 days 3

• Treatment may be extended if healing is incomplete after 10 days of therapy 3

• Higher dosages of acyclovir may be required for severe cases, particularly in immunocompromised patients 3

Recurrent Episodes Treatment

• Episodic therapy options for recurrent episodes include:

  • Valacyclovir 500 mg orally twice daily for 5 days 1
  • Acyclovir 400 mg orally three times daily for 5 days 1
  • Acyclovir 800 mg orally twice daily for 5 days 1
  • Acyclovir 200 mg orally five times daily for 5 days 1
  • Famciclovir 125 mg orally twice daily for 5 days 1

• Episodic therapy is most effective when started during the prodrome or within 1 day after onset of lesions 3

• Patients should be provided with medication or a prescription to initiate treatment at the first sign of prodrome or genital lesions 3

Suppressive Therapy

• Daily suppressive therapy is recommended for patients with frequent recurrences (≥6 episodes per year) 3, 1

• Suppressive therapy options include:

  • Valacyclovir 1 g orally once daily 1, 2
  • Valacyclovir 500 mg orally once daily 1, 2
  • Acyclovir 400 mg orally twice daily 1, 2
  • Famciclovir 250 mg orally twice daily 1, 2

• Suppressive therapy reduces recurrence frequency by ≥75% 3, 4

• Safety and efficacy have been documented for acyclovir for up to 6 years and for valacyclovir and famciclovir for 1 year 3

• After 1 year of continuous suppressive therapy, consider discontinuation to assess recurrence frequency 3

Important Clinical Considerations

• Topical acyclovir is substantially less effective than oral therapy and is not recommended 3
• Valacyclovir is the only antiviral approved for once-daily dosing for suppressive therapy, which may improve patient adherence 5
• Comparative studies suggest valacyclovir may be somewhat more effective than famciclovir for suppression of genital herpes and associated viral shedding 6
• Single-day famciclovir treatment does not appear to shorten time to next recurrence or lead to antiviral resistance 7

Patient Education and Counseling

• Patients should be counseled about:

  • The natural history of genital herpes, including potential for recurrent episodes, asymptomatic viral shedding, and sexual transmission 3
  • Abstaining from sexual activity when lesions or prodromal symptoms are present 3, 1
  • Informing sex partners about having genital herpes 3
  • Using condoms during all sexual exposures with new or uninfected partners 3, 1
  • The risk of neonatal infection, especially for childbearing-aged women 3
  • The fact that antiviral medications control symptoms but do not eradicate the virus or prevent all recurrences 1

• Asymptomatic viral shedding occurs more frequently in patients with HSV-2 infection than HSV-1 infection and in patients who have had genital herpes for less than 12 months 3

Special Considerations

• HSV-1 causes 5-30% of first-episode cases of genital herpes, with clinical recurrences being much less frequent than with HSV-2 3
• Identification of the infecting strain (HSV-1 vs HSV-2) has prognostic importance and may be useful for counseling 3
• Antiviral resistance is rare in immunocompetent patients but more common in immunocompromised individuals 2
• For pregnant women with genital herpes, healthcare providers should be informed about the HSV infection 3