What is the recommended treatment for HSV (Herpes Simplex Virus) 1 genital infection?

Treatment for HSV-1 Genital Infection

For first-episode HSV-1 genital infection, treat with valacyclovir 1 g orally twice daily for 7-10 days, which is the CDC-recommended regimen that addresses both symptom control and viral shedding. 1, 2

First Clinical Episode Management

Treatment should be initiated as soon as possible, ideally within 72 hours of symptom onset:

• Valacyclovir 1 g orally twice daily for 7-10 days (preferred regimen) 1, 2, 3

• Alternative options include:

  • Acyclovir 400 mg orally three times daily for 7-10 days 1, 2, 3
  • Acyclovir 200 mg orally five times daily for 7-10 days 2, 3
  • Famciclovir 250 mg orally three times daily for 7-10 days 2, 3

• Extend treatment beyond 10 days if healing remains incomplete 2, 3

• For severe disease requiring hospitalization, use acyclovir 5-10 mg/kg IV every 8 hours for 5-7 days or until clinical resolution 1, 3

Recurrent Episode Management

HSV-1 genital infections recur much less frequently than HSV-2, which fundamentally changes long-term management strategy. 2, 3

For the rare recurrences that do occur, use valacyclovir 500 mg orally twice daily for 5 days:

• This shorter 5-day course is appropriate for HSV-1 recurrences (versus the 7-10 day course for first episodes) 1, 2
• Alternative regimens include:
  • Acyclovir 400 mg orally three times daily for 5 days 1, 3
  • Acyclovir 800 mg orally twice daily for 5 days 1, 3
  • Famciclovir 125 mg orally twice daily for 5 days 1, 3

Critical timing consideration: Treatment is most effective when started during the prodromal period or within 1 day after lesion onset; delayed treatment beyond 72 hours significantly reduces effectiveness 1, 3

• Provide patients with medication or a prescription to self-initiate treatment at the first sign of prodrome or genital lesions 1, 3

Suppressive Therapy Considerations

Suppressive therapy is rarely needed for HSV-1 genital infections due to infrequent recurrences. 2

However, if recurrences are frequent (≥6 episodes per year):

• Valacyclovir 500 mg to 1 g orally once daily 2
• Acyclovir 400 mg orally twice daily 1, 3
• Suppressive therapy reduces recurrence frequency by ≥75% 1, 3
• After 1 year of continuous suppressive therapy, discontinue to reassess recurrence frequency 3

Essential Patient Counseling

Type-specific identification (HSV-1 vs HSV-2) has critical prognostic value and should be confirmed through type-specific serologic testing. 2, 3

Counsel patients on the following points:

• HSV-1 genital infections recur much less frequently than HSV-2, which has important implications for long-term prognosis 2, 3
• Genital herpes is incurable but controllable with antiviral therapy 2
• Asymptomatic viral shedding can occur, though less frequently with HSV-1 than HSV-2 2, 3
• Abstain from sexual activity when lesions or prodromal symptoms are present 3
• Use condoms during all sexual exposures with new or uninfected partners 2, 3
• Inform sex partners about having genital herpes 3
• Childbearing-aged women must inform obstetric providers due to neonatal transmission risk 2, 3
• Antiviral medications control symptoms but do not eradicate latent virus or prevent all recurrences 1, 3

Important Clinical Pitfalls

Do not use topical acyclovir—it is substantially less effective than oral therapy and is not recommended. 1, 3

Special populations requiring modified dosing:

• Immunocompromised patients: Acyclovir 400 mg orally three to five times daily until clinical resolution 1
• HIV-infected patients: Consider acyclovir 400 mg orally three to five times daily or famciclovir 500 mg twice daily 1
• Pregnant women: Inform healthcare providers about HSV infection; discuss safety of systemic therapy 3