What are the treatment options for Herpes 2 (Genital Herpes)?

Treatment of Herpes Simplex Virus Type 2 (Genital Herpes)

For first-episode genital herpes, treat with valacyclovir 1 g orally twice daily for 7-10 days; for recurrent episodes, use valacyclovir 500 mg twice daily for 5 days initiated within 1 day of symptom onset; and for patients with ≥6 recurrences per year, prescribe daily suppressive therapy with valacyclovir 1 g once daily. 1

First Clinical Episode

Treatment duration is longer for initial infections compared to recurrences:

• Valacyclovir 1 g orally twice daily for 7-10 days is the preferred first-line regimen 1
• Alternative options include:
  • Acyclovir 400 mg orally three times daily for 7-10 days 1
  • Acyclovir 200 mg orally five times daily for 7-10 days 1, 2
  • Famciclovir 250 mg orally three times daily for 7-10 days 1
• Extend treatment beyond 10 days if healing is incomplete 1

Recurrent Episodes (Episodic Therapy)

Timing is critical—episodic therapy must be started during the prodrome or within 1 day of lesion onset to be effective:

• Valacyclovir 500 mg orally twice daily for 5 days is the preferred regimen due to convenient dosing 1, 3
• Alternative 5-day regimens include:
  • Acyclovir 400 mg orally three times daily 1, 3
  • Acyclovir 800 mg orally twice daily 1, 3, 2
  • Acyclovir 200 mg orally five times daily 1, 3
  • Famciclovir 125 mg orally twice daily 1, 3
• Treatment delayed beyond 72 hours significantly reduces effectiveness 1
• Single-day famciclovir 1000 mg twice daily for 1 day is FDA-approved and reduces healing time by approximately 1.2 days compared to placebo 4

The evidence shows that shorter courses (2-5 days) are as effective as standard 5-day regimens for recurrent episodes. A 2-day course of acyclovir 800 mg three times daily significantly reduced lesion duration (4 days vs 6 days with placebo) 5. Single-day famciclovir does not shorten time to next recurrence or promote antiviral resistance 6.

Suppressive Therapy

Daily suppressive therapy is indicated for patients with ≥6 recurrences per year:

• Valacyclovir 1 g orally once daily (preferred for once-daily convenience) 1, 3, 2
• Alternative: Valacyclovir 500 mg orally once daily 1, 3
• Acyclovir 400 mg orally twice daily 1, 3, 2
• Famciclovir 250 mg orally twice daily 1, 3, 2

Benefits of suppressive therapy:

• Reduces recurrence frequency by ≥75% 1, 3, 2
• Reduces asymptomatic viral shedding 1
• Reduces transmission risk to sexual partners 1
• Suppressive therapy with famciclovir 250 mg twice daily resulted in 39% of patients remaining recurrence-free at 6 months and 29% at 12 months, compared to only 10% and 6% with placebo 4

After 1 year of suppressive therapy, consider discontinuation to reassess recurrence frequency 1, 3

Special Populations

HIV-Infected Patients

• Require closer monitoring and may need longer treatment courses 1
• Famciclovir 500 mg twice daily is effective in reducing recurrences and subclinical shedding in HIV-infected patients 1
• Famciclovir 500 mg twice daily for 7 days is comparable to acyclovir 400 mg five times daily for 7 days in HIV-infected patients with CD4+ counts below 200 cells/mm³ 4

Pregnant Women

• Safety considerations are important; ciprofloxacin is contraindicated during pregnancy 1
• Routine suppressive therapy is not recommended during pregnancy for recurrent genital herpes, as the safety of systemic acyclovir and valacyclovir has not been definitively established 3

Severe Disease Requiring Hospitalization

• Acyclovir 5-10 mg/kg IV every 8 hours for 5-7 days or until clinical resolution 2

Critical Clinical Considerations and Pitfalls

Topical acyclovir is substantially less effective than oral therapy and should not be used 1, 3, 2

Antiviral medications control symptoms but do not eradicate latent virus or affect subsequent recurrences after discontinuation 1, 3, 2

If symptoms persist beyond expected healing time, consider:

• Incorrect diagnosis 1
• Co-infection with another STD 1, 3
• HIV infection 1
• Poor medication adherence 1
• Antiviral resistance (rare in immunocompetent patients) 1, 2

For acyclovir-resistant HSV:

• Suspect resistance if lesions do not begin to resolve within 7-10 days of therapy 3
• IV foscarnet 40 mg/kg every 8 hours is the treatment of choice 1, 3
• Resistance is more common in immunocompromised individuals 2
• No penciclovir resistance has been observed with famciclovir use in immunocompetent patients 6

Avoid valacyclovir 8 g per day in immunocompromised patients due to risk of hemolytic uremic syndrome/thrombotic thrombocytopenic purpura 3

Transmission Prevention Counseling

Patients must be counseled on the following:

• Abstain from sexual activity when lesions or prodromal symptoms are present 1, 3, 2
• Asymptomatic viral shedding can occur and lead to transmission 1, 3, 2
• Use condoms consistently during all sexual exposures with new or uninfected partners 1, 3, 2
• Inform sexual partners about having genital herpes 3
• Suppressive therapy reduces but does not eliminate transmission risk 1