What is the recommended follow-up and treatment plan for a patient with a history of Herpes Simplex Virus (HSV)?

Follow-Up Management of Herpes Simplex Virus (HSV)

For patients with a history of HSV, chronic suppressive therapy is not routinely required after acute lesions resolve, but daily suppressive antiviral therapy should be offered to those experiencing frequent or severe recurrences (≥6 per year), with oral acyclovir 400 mg twice daily, famciclovir 250 mg twice daily, or valacyclovir 500-1000 mg daily as first-line options. 1

Initial Assessment and Counseling

When following up patients with HSV history, comprehensive counseling is essential and should address:

• Natural history education: Inform patients that HSV is a chronic, lifelong infection with potential for recurrent episodes, asymptomatic viral shedding, and sexual transmission even during symptom-free periods 1, 2
• Transmission risk: Emphasize that asymptomatic viral shedding occurs more frequently in HSV-2 infection (compared to HSV-1) and during the first 12 months after acquisition 1
• Barrier protection: Recommend latex condoms during every sexual encounter to reduce transmission risk, with strict avoidance of sexual contact when lesions or prodromal symptoms are present 1
• Partner notification: Encourage disclosure to sexual partners and explain that partners may be infected despite being asymptomatic 1, 3

Treatment Strategy Based on Recurrence Pattern

For Infrequent Recurrences (<6 episodes/year)

Episodic therapy is appropriate for patients with infrequent outbreaks 1:

• Acyclovir: 400 mg orally three times daily for 5 days, OR 800 mg twice daily for 5 days 1, 3
• Valacyclovir: 500 mg twice daily for 3 days 1, 3
• Famciclovir: 125 mg twice daily for 5 days 1

Critical timing: Treatment must be initiated at first sign of prodrome or within 24 hours of lesion onset for maximum efficacy 1. Provide patients with a prescription to keep on hand for immediate self-initiation 1.

For Frequent Recurrences (≥6 episodes/year)

Daily suppressive therapy reduces recurrence frequency by ≥75% and is the preferred strategy 1:

• Acyclovir: 400 mg orally twice daily 1, 3
• Famciclovir: 250 mg orally twice daily 1
• Valacyclovir: 500-1000 mg once daily (1000 mg for most patients; 500 mg acceptable for those with ≤9 recurrences/year) 1, 3

Duration considerations: Safety and efficacy are documented for acyclovir up to 6 years, and for valacyclovir/famciclovir up to 1 year 1. After 1 year of continuous therapy, reassess the need for continuation, as recurrence frequency naturally decreases over time in many patients 1, 4.

Special Populations

HIV-Infected Patients

• Suppressive dosing: Use valacyclovir 500 mg twice daily (not once daily) for patients with CD4+ count ≥100 cells/mm³ 3
• Monitoring: HIV-infected patients may experience slower healing and treatment failures with any regimen, requiring closer follow-up 1
• Acyclovir-resistant HSV: Consider IV foscarnet or cidofovir for resistant isolates (which are also ganciclovir-resistant) 1

Pregnant Women

• Suppressive therapy in late pregnancy: While controversial and not routinely recommended, acyclovir prophylaxis may be indicated for women with frequent, severe recurrences to prevent neonatal transmission 1
• Safety profile: No pattern of adverse pregnancy outcomes has been reported with acyclovir exposure 1
• Neonatal risk counseling: All patients, including male partners, should understand the risk of neonatal infection 1

Ocular HSV (Conjunctivitis/Keratitis)

For patients with HSV eye involvement, a different approach is required 1, 5:

• Topical therapy: Ganciclovir 0.15% gel 3-5 times daily (preferred due to less toxicity) OR trifluridine 1% solution 5-8 times daily (avoid >2 weeks due to epithelial toxicity) 1, 5
• Oral antivirals: Add acyclovir 200-400 mg five times daily, valacyclovir 500 mg 2-3 times daily, or famciclovir 250 mg twice daily 1, 5
• Follow-up timing: Schedule within 1 week to assess visual acuity, IOP, and slit-lamp findings 1, 5
• Critical warning: Never use topical corticosteroids alone without antiviral coverage, as they potentiate HSV epithelial infections 1, 5

Long-Term Follow-Up Schedule

Routine Monitoring

• Annual reassessment: After 1 year of suppressive therapy, discontinue temporarily to evaluate current recurrence rate, as frequency naturally decreases over time in most patients 1, 4
• Recurrence tracking: One-third of patients experience ≥2 fewer recurrences per year between years 1 and 2, with median decrease of 2 recurrences between years 1 and 5 4
• Variability acknowledgment: 25% of patients may experience increased recurrences even after 4+ years, illustrating individual variability 4

Medication Management

• Missed doses: Instruct patients to take missed doses as soon as remembered, but never double the next dose 3
• Hydration: Advise adequate fluid intake, particularly important with acyclovir 3
• Resistance monitoring: Suppressive therapy has not been associated with clinically significant acyclovir resistance in immunocompetent patients 1

Common Pitfalls to Avoid

• Delayed treatment initiation: Episodic therapy loses effectiveness if started >24 hours after symptom onset for recurrences or >72 hours for initial episodes 1
• Inadequate counseling about asymptomatic shedding: Patients must understand that transmission can occur without visible lesions, and suppressive therapy reduces but does not eliminate asymptomatic viral shedding 1
• Premature discontinuation of suppressive therapy: Some patients may benefit from continued suppression beyond 1 year, particularly those with severe psychological distress from recurrences 1
• Failure to provide advance prescriptions: For episodic therapy to be effective, patients need medication readily available for immediate self-initiation at first prodrome 1
• Using topical acyclovir: Topical therapy is substantially less effective than systemic treatment and should be avoided 1