What is the treatment for genital herpes?

Treatment of Genital Herpes

For genital herpes, use oral antiviral therapy with acyclovir, valacyclovir, or famciclovir—the specific regimen depends on whether this is a first episode, recurrent outbreak, or if suppressive therapy is needed. 1

First Clinical Episode

For patients presenting with their first episode of genital herpes, initiate treatment immediately with one of the following regimens for 7-10 days 2, 3:

• Valacyclovir 1 g orally twice daily (preferred for convenience) 1, 2
• Acyclovir 400 mg orally three times daily 1, 2
• Acyclovir 200 mg orally five times daily 1, 3
• Famciclovir 250 mg orally three times daily 1, 2

Extend treatment beyond 10 days if healing is incomplete. 2 The median time to lesion healing is approximately 9 days, with cessation of pain at 5 days and viral shedding at 3 days. 4

Important Considerations for First Episodes

• Identify whether the infection is HSV-1 or HSV-2, as HSV-1 causes 5-30% of first episodes but recurs much less frequently than HSV-2. 2 This has significant prognostic implications for counseling. 1, 2
• For severe herpes proctitis, use higher doses: acyclovir 400 mg orally five times daily for 10 days. 3

Recurrent Episodes (Episodic Therapy)

For patients with recurrent outbreaks, provide medication to self-initiate at the first sign of prodrome or lesions—treatment is most effective when started within 24 hours of symptom onset. 5, 4

Choose one of these 5-day regimens 2, 5:

• Valacyclovir 500 mg orally twice daily (preferred for convenience and efficacy) 2, 5
• Acyclovir 400 mg orally three times daily 1, 5
• Acyclovir 800 mg orally twice daily 1, 5
• Acyclovir 200 mg orally five times daily 1, 5
• Famciclovir 125 mg orally twice daily 1, 5

Episodic therapy reduces median time to lesion healing from 6 days to 4 days and cessation of viral shedding from 4 days to 2 days compared to placebo. 4

Clinical Pearl

Avoid topical acyclovir—it is substantially less effective than oral therapy and should not be used. 2, 5

Suppressive Therapy

Offer daily suppressive therapy to all patients with symptomatic HSV-2 infection, particularly those with ≥6 recurrences per year. 1, 5 Suppressive therapy reduces recurrence frequency by ≥75% and decreases asymptomatic viral shedding. 2, 5

Recommended daily regimens 2, 3, 5:

• Valacyclovir 1 g orally once daily (most convenient option) 2, 5
• Valacyclovir 500 mg orally once daily (less effective for patients with ≥10 recurrences per year) 1, 6
• Acyclovir 400 mg orally twice daily 1, 2
• Famciclovir 250 mg orally twice daily 1, 2

Duration and Reassessment

• Safety and efficacy are documented for acyclovir up to 6 years and for valacyclovir/famciclovir up to 1 year. 2
• After 1 year of continuous suppressive therapy, consider discontinuing to reassess recurrence frequency. 2, 5

Transmission Prevention

Suppressive therapy reduces transmission to uninfected sexual partners through suppression of viral shedding. 1 This applies to heterosexual couples, men who have sex with men, women who have sex with women, and transgender persons. 1 However, suppressive therapy does NOT effectively decrease transmission risk in persons with HIV/HSV-2 coinfection. 1

Severe Disease Requiring Hospitalization

For patients with severe disease, disseminated infection, pneumonitis, hepatitis, or CNS complications (meningitis/encephalitis), use acyclovir 5-10 mg/kg IV every 8 hours for 5-7 days or until clinical resolution. 1, 2, 3

Special Populations

HIV-Infected Patients

Immunocompromised patients may have prolonged, severe, or atypical lesions. 1

• Use higher doses: acyclovir 400 mg orally three to five times daily until clinical resolution 1
• Famciclovir 500 mg twice daily is effective for decreasing recurrences and subclinical shedding 1
• For suppressive therapy in HIV-infected patients: valacyclovir 500 mg twice daily reduces recurrences (65% recurrence-free at 6 months vs 26% with placebo) 4
• Avoid high-dose valacyclovir (8 g/day) in immunocompromised patients due to risk of hemolytic uremic syndrome or thrombotic thrombocytopenic purpura. 1

Acyclovir-Resistant HSV

Suspect resistance if lesions persist despite acyclovir treatment. 1 All acyclovir-resistant strains are also resistant to valacyclovir, and most to famciclovir. 1

• First-line for resistant cases: foscarnet 40 mg/kg IV every 8 hours until clinical resolution 1
• Alternative: topical cidofovir gel 1% applied once daily for 5 consecutive days 1
• Emerging options include brincidofovir and imiquimod (case report evidence only) 1

Pregnancy

The safety of systemic acyclovir and valacyclovir in pregnancy is not fully established, though accumulated registry data do not show increased risk of major birth defects. 1

• First clinical episode during pregnancy may be treated with oral acyclovir 1
• For life-threatening maternal HSV infection (disseminated infection, encephalitis, pneumonitis, hepatitis), use IV acyclovir 1
• Routine suppressive therapy in pregnant women with recurrent genital herpes is not currently recommended. 1
• Pregnant women with genital herpes should inform their healthcare providers about the infection 2

Essential Patient Counseling

All patients require comprehensive counseling 2, 5:

• Genital herpes is a chronic, incurable viral disease—antivirals control symptoms but do not eradicate the virus or prevent all recurrences. 5
• Abstain from sexual activity when lesions or prodromal symptoms are present. 2, 3
• Inform all sex partners about having genital herpes. 2
• Use condoms during all sexual exposures with new or uninfected partners. 2, 3
• Asymptomatic viral shedding occurs and can transmit infection—this is more frequent with HSV-2 than HSV-1 and in patients with infection <12 months. 2, 5
• Discuss the risk of neonatal transmission, especially for women of childbearing age. 2

Management of Sexual Partners

Sexual partners should be evaluated and counseled. 1 Symptomatic partners should be treated identically. 1 Even asymptomatic partners of newly diagnosed patients should be questioned about typical and atypical genital lesions and encouraged to seek evaluation if lesions appear. 1