What is the recommended treatment for genital herpes?

Treatment for Genital Herpes

For first-episode genital herpes, treat with oral antiviral therapy for 7-10 days using valacyclovir 1 g twice daily, acyclovir 400 mg three times daily, or famciclovir 250 mg three times daily; for recurrent episodes, use episodic therapy with valacyclovir 500 mg twice daily for 3-5 days or consider daily suppressive therapy with valacyclovir 1 g once daily if experiencing ≥6 recurrences per year. 1, 2, 3

First Clinical Episode Treatment

Initial presentation requires 7-10 days of antiviral therapy, with the following CDC-recommended options 4, 2:

• Valacyclovir 1 g orally twice daily for 7-10 days (preferred for convenience) 4, 2, 3
• Acyclovir 400 mg orally three times daily for 7-10 days 4, 2
• Acyclovir 200 mg orally five times daily for 7-10 days 4, 5
• Famciclovir 250 mg orally three times daily for 7-10 days 4, 2, 6

Extend treatment beyond 10 days if healing is incomplete at the end of the initial course 4, 2. Therapy is most effective when initiated within 48 hours of symptom onset 4.

Severe Disease Requiring Hospitalization

• Acyclovir 5-10 mg/kg IV every 8 hours for 5-7 days or until clinical resolution for patients with severe first episodes 2, 5

Recurrent Episodes: Episodic Therapy

Start treatment at the first sign of prodrome (tingling, itching, burning) or within 1 day of lesion onset for maximum effectiveness 1, 2.

Preferred regimens for episodic treatment 1, 2, 3:

• Valacyclovir 500 mg orally twice daily for 3 days (FDA-approved shortest regimen) 1, 3
• Valacyclovir 500 mg orally twice daily for 5 days 1
• Acyclovir 800 mg orally twice daily for 5 days 1, 5
• Acyclovir 400 mg orally three times daily for 5 days 1, 5
• Famciclovir 125 mg orally twice daily for 5 days 1, 6

Provide patients with medication or a prescription in advance so they can self-initiate treatment immediately when symptoms begin 2.

Chronic Suppressive Therapy

Recommend daily suppressive therapy for patients with ≥6 recurrences per year to reduce outbreak frequency by ≥75% 1, 2.

Suppressive therapy options 1, 2, 3:

• Valacyclovir 1 g orally once daily (standard dose) 1, 2, 3
• Valacyclovir 500 mg orally once daily (for patients with ≤9 recurrences per year) 1, 3
• Acyclovir 400 mg orally twice daily 1, 2
• Famciclovir 250 mg orally twice daily 1, 2, 6

Safety has been documented for acyclovir up to 6 years and valacyclovir/famciclovir for 1 year of continuous use 1, 2. After 1 year of suppressive therapy, consider discontinuation to reassess recurrence frequency 1, 2.

Suppressive Therapy for Transmission Reduction

• Valacyclovir 500 mg orally once daily reduces transmission to uninfected partners in patients with ≤9 recurrences per year 1, 3

Special Populations

HIV-Infected Patients

• Valacyclovir 500 mg orally twice daily for chronic suppression in patients with CD4+ count ≥100 cells/mm³ 1
• Famciclovir 500 mg orally twice daily for 7 days for treatment of recurrent orolabial or genital herpes 5, 6

Pregnant Women

• Acyclovir prophylaxis from 36 weeks gestation until delivery is recommended for women with a history of genital herpes 7
• Routine suppressive therapy during pregnancy for recurrent herpes is not universally recommended, though the safety of acyclovir and valacyclovir has not been definitively established 1

Critical Clinical Considerations

Avoid topical acyclovir—it is substantially less effective than oral therapy and should not be used 4, 1, 2, 5.

Suspect acyclovir resistance if lesions do not begin resolving within 7-10 days of therapy, particularly in immunocompromised patients 1. Resistance is rare in immunocompetent individuals 2, 8.

For proven or suspected acyclovir resistance, use foscarnet 40 mg/kg IV every 8 hours 1.

Do not use valacyclovir 8 g/day in immunocompromised patients due to risk of hemolytic uremic syndrome/thrombotic thrombocytopenic purpura 1.

Viral Strain Considerations

HSV-1 causes 5-30% of first-episode genital herpes but recurs much less frequently than HSV-2 4, 2. Identifying the viral strain (HSV-1 vs HSV-2) has prognostic importance and helps guide counseling about recurrence expectations 4, 2.

HSV-2 infection carries higher risk for HIV acquisition and more frequent asymptomatic viral shedding, especially in the first 12 months after infection 4, 2.

Essential Patient Counseling

Counsel all patients about the following 4, 1, 2:

• Genital herpes is a recurrent, incurable viral disease; antivirals control symptoms but do not eradicate the virus 4, 1
• Abstain from sexual activity when lesions or prodromal symptoms are present 4, 1, 2
• Asymptomatic viral shedding occurs and can transmit infection even without visible lesions 4, 1, 2
• Inform sex partners about having genital herpes 4, 2
• Use condoms during all sexual exposures with new or uninfected partners 4, 1, 2
• Women of childbearing age should inform healthcare providers about HSV infection due to neonatal transmission risk 2