What is the recommended treatment for a genital herpes flare?

Treatment for Genital Herpes Flare

The recommended treatment for a genital herpes flare is valacyclovir 500 mg orally twice daily for 5 days, which should be started at the first sign of symptoms or prodrome for maximum effectiveness. 1, 2

Treatment Options Based on Clinical Presentation

First Clinical Episode

• For first episodes of genital herpes, the Centers for Disease Control and Prevention (CDC) recommends:
  • Valacyclovir 1 g orally twice daily for 7-10 days 1, 3
  • Acyclovir 400 mg orally three times daily for 7-10 days 1
  • Acyclovir 200 mg orally five times daily for 7-10 days 4, 1
  • Famciclovir 250 mg orally three times daily for 7-10 days 1
• Treatment may be extended if healing is incomplete after 10 days 1

Recurrent Episodes (Current Flare)

• For recurrent episodes, the CDC recommends the following episodic treatment options:
  • Valacyclovir 500 mg orally twice daily for 5 days (preferred regimen) 1, 2, 3
  • Acyclovir 400 mg orally three times daily for 5 days 4, 1, 2
  • Acyclovir 800 mg orally twice daily for 5 days 1, 2
  • Acyclovir 200 mg orally five times daily for 5 days 4, 1, 2
  • Famciclovir 125 mg orally twice daily for 5 days 4, 1, 2
• Treatment is most effective when started during the prodrome or within 1 day after onset of lesions 1, 2
• Patients should be provided with medication or a prescription to initiate treatment promptly at the first sign of prodrome or genital lesions 1, 2

Severe Disease Requiring Hospitalization

• For severe disease requiring hospitalization, the CDC recommends:
  • Acyclovir 5-10 mg/kg IV every 8 hours for 5-7 days or until clinical resolution 4, 1

Long-term Management Options

Suppressive Therapy

• For patients with frequent recurrences (≥6 episodes per year), daily suppressive therapy is recommended: 4, 1, 2
  • Valacyclovir 1 g orally once daily 4, 1, 2, 3
  • Valacyclovir 500 mg orally once daily (for patients with 9 or fewer recurrences per year) 4, 1, 2, 3
  • Acyclovir 400 mg orally twice daily 4, 1, 2
  • Famciclovir 250 mg orally twice daily 4, 1, 2
• Suppressive therapy reduces recurrence frequency by ≥75% 4, 1, 2
• Safety and efficacy have been documented for acyclovir for up to 6 years and for valacyclovir and famciclovir for 1 year 1
• Consider discontinuation after 1 year to assess recurrence frequency 1

Important Clinical Considerations

• Topical acyclovir is substantially less effective than oral therapy and is not recommended 4, 1, 2
• Antiviral resistance is rare in immunocompetent patients but more common in immunocompromised individuals 4, 1
• Valacyclovir is the only antiviral drug approved for a once-daily dose of suppressive therapy and for a 3-day regimen of episodic treatment 5
• Patients should be advised that antiviral medications control symptoms but do not eradicate the virus or prevent all recurrences 4, 1

Patient Education and Prevention

• Patients should abstain from sexual activity when lesions or prodromal symptoms are present 4, 1, 2
• Condoms should be used during all sexual exposures with new or uninfected partners 4, 1, 2
• Patients should be informed about asymptomatic viral shedding, which can lead to transmission 4, 1, 2
• Patients should inform sex partners about having genital herpes 1
• For pregnant women with genital herpes, healthcare providers should be informed about the HSV infection 1

Follow-up Recommendations

• Patients with persistent symptoms beyond 5 days of treatment should be considered for extended treatment 2
• Evaluate for potential co-infections if discharge and pelvic pain persist 2
• Consider psychological adjustment to having genital herpes as part of comprehensive management 2, 6