What is the treatment for recurrent sacral herpes?

Treatment of Recurrent Sacral Herpes

For recurrent sacral herpes (a manifestation of genital herpes), initiate episodic antiviral therapy with valacyclovir 500 mg orally twice daily for 5 days, starting at the first sign of prodromal symptoms or within 24 hours of lesion onset. 1, 2

Episodic Treatment Options

First-line episodic therapy should be started during the prodrome or within 1 day after onset of lesions for maximum benefit 3, 1:

• Valacyclovir 500 mg orally twice daily for 5 days (preferred for convenience) 1, 2
• Acyclovir 400 mg orally three times daily for 5 days 3, 1
• Acyclovir 800 mg orally twice daily for 5 days 3, 1
• Acyclovir 200 mg orally five times daily for 5 days 3
• Famciclovir 125 mg orally twice daily for 5 days 3, 2

Patients should be provided with a prescription or medication supply to self-initiate treatment immediately at symptom onset, as early treatment significantly reduces lesion duration and viral shedding 3, 4.

Suppressive Therapy for Frequent Recurrences

If the patient experiences ≥6 recurrences per year, transition to daily suppressive therapy, which reduces recurrence frequency by ≥75% 3, 1, 2:

• Valacyclovir 1,000 mg orally once daily (most convenient dosing) 1, 2
• Valacyclovir 500 mg orally once daily (less effective for ≥10 episodes/year) 3
• Acyclovir 400 mg orally twice daily 3, 1
• Famciclovir 250 mg orally twice daily 3, 1

Safety data supports acyclovir use for up to 6 years and valacyclovir/famciclovir for at least 1 year 3. After 1 year of continuous suppressive therapy, discuss discontinuation with the patient to reassess recurrence frequency, as episodes often decrease over time 3, 2.

Important Clinical Considerations

Avoid topical acyclovir, as it is substantially less effective than oral therapy 1, 4, 2.

Counsel patients that:

• Antiviral medications control symptoms but do not eradicate the virus or prevent all recurrences 2
• Asymptomatic viral shedding can occur even on suppressive therapy, potentially leading to transmission 3, 2
• Sexual activity should be avoided when lesions or prodromal symptoms are present 2
• Condoms should be used during all sexual exposures with new or uninfected partners 2

Severe Disease Management

For severe disease requiring hospitalization (disseminated infection, complications involving CNS, pneumonitis, or hepatitis):

• Acyclovir 5-10 mg/kg IV every 8 hours for 5-7 days or until clinical resolution 3, 1

Antiviral Resistance

Antiviral resistance is rare in immunocompetent patients but more common in immunocompromised individuals 1, 4. Suppressive therapy has not been associated with emergence of clinically significant acyclovir resistance among immunocompetent patients 3. If treatment failure occurs, consider viral cultures with susceptibility testing 4.