Treatment for Herpes Simplex Virus (HSV)
Oral antiviral medications—valacyclovir, acyclovir, and famciclovir—are the mainstay of treatment for HSV infections, with valacyclovir preferred for most patients due to convenient dosing and equivalent efficacy. 1
First Clinical Episode Treatment
For initial genital herpes outbreaks, longer treatment courses are required to control the more extensive disease:
- Valacyclovir 1 g orally twice daily for 7-10 days is the preferred first-line regimen 2, 1
- Alternative regimens include:
- Treatment may be extended beyond 10 days if healing is incomplete 2, 1
Recurrent Episodes Treatment
For recurrent outbreaks, shorter 5-day courses are effective:
- Valacyclovir 500 mg orally twice daily for 5 days is the preferred episodic therapy 1, 3
- Alternative regimens include:
Critical Timing Considerations
- Start treatment during the prodromal period or within 1 day of lesion onset for maximum benefit 2, 1, 3
- Treatment delayed beyond 72 hours has significantly reduced effectiveness 1, 3
- Patients should be provided with medication or a prescription in advance to enable early self-initiated treatment 2
Suppressive Therapy
For patients with frequent recurrences (≥6 episodes per year), daily suppressive therapy is highly effective:
- Valacyclovir 1 g orally once daily (preferred for convenience) 1
- Alternative suppressive regimens:
- Suppressive therapy reduces recurrence frequency by ≥75% 2, 1
- Suppressive therapy also reduces asymptomatic viral shedding and may reduce transmission risk to sexual partners 1, 3
- After 1 year of continuous suppressive therapy, discontinue to reassess the patient's recurrence rate 2, 1
Special Populations
HIV-Infected Patients
- HIV-infected patients require close monitoring and may need longer treatment courses than HIV-negative patients 1
- Higher doses may be necessary: famciclovir 500 mg twice daily has demonstrated effectiveness in reducing recurrences and subclinical shedding in this population 1
- Treatment failures occur more frequently, especially with shorter-course regimens 2
Pregnant Women
- Standard antiviral dosing regimens are used during pregnancy 1
- Ciprofloxacin is contraindicated during pregnancy 2, 1
- No adverse effects of HSV antivirals on pregnancy outcomes have been reported 2
Critical Clinical Pitfalls to Avoid
- Never use topical acyclovir—it is substantially less effective than oral therapy and should be avoided 2, 1
- Do not expect antivirals to eradicate latent virus; they only control symptoms during active treatment 2, 1
- Failing to provide advance prescriptions for episodic therapy prevents early self-initiated treatment 2
- Not considering suppressive therapy in patients with frequent recurrences (≥6 per year) 1
Treatment Failure Considerations
If symptoms persist beyond expected healing time, consider:
- Incorrect diagnosis or co-infection with another sexually transmitted disease 1
- HIV infection (undiagnosed) 1
- Poor medication adherence 1
- Antiviral resistance (rare in immunocompetent patients)—treat with IV foscarnet 1
Counseling and Transmission Prevention
- Patients should abstain from sexual activity when lesions or prodromal symptoms are present 2, 1
- Encourage consistent condom use with new or uninfected partners 2, 1
- Asymptomatic viral shedding occurs more frequently with HSV-2 than HSV-1 and in the first 12 months after infection 2
- Suppressive therapy can reduce transmission risk to sexual partners 1, 3
- Inform childbearing-aged women to notify healthcare providers about HSV infection during pregnancy 2