What is the first line treatment for genital herpes?

First-Line Treatment for Genital Herpes

For first-episode genital herpes, the CDC recommends valacyclovir 1 g orally twice daily for 7-10 days as first-line treatment. 1, 2

Initial Episode Management

The treatment approach differs based on whether this is a first episode or recurrent outbreak:

First Clinical Episode (Primary Infection)

• Valacyclovir 1 g orally twice daily for 7-10 days is the preferred first-line regimen 1, 2
• Alternative equally effective options include: 1
  • Acyclovir 400 mg orally three times daily for 7-10 days
  • Acyclovir 200 mg orally five times daily for 7-10 days
  • Famciclovir 250 mg orally three times daily for 7-10 days
• Treatment may be extended beyond 10 days if healing is incomplete 1, 2
• For severe disease requiring hospitalization, use acyclovir 5-10 mg/kg IV every 8 hours for 5-7 days or until clinical resolution 1

Recurrent Episodes (Episodic Therapy)

• Valacyclovir 500 mg orally twice daily for 5 days is the CDC-recommended first-line episodic treatment 3, 1
• Alternative regimens for recurrent episodes include: 3, 1
  • Acyclovir 400 mg orally three times daily for 5 days
  • Acyclovir 800 mg orally twice daily for 5 days
  • Acyclovir 200 mg orally five times daily for 5 days
  • Famciclovir 125 mg orally twice daily for 5 days
• Episodic therapy is most effective when started during prodrome or within 1 day of lesion onset 3, 1
• Patients should receive a prescription to self-initiate treatment at first sign of symptoms 1, 2

Suppressive Therapy for Frequent Recurrences

For patients with ≥6 episodes per year, daily suppressive therapy is recommended: 3, 1, 2

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

Suppressive therapy reduces recurrence frequency by ≥75% and is safe for up to 6 years with acyclovir and 1 year with valacyclovir 3, 1

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

Critical Clinical Pitfalls to Avoid

• Never use topical acyclovir—it is substantially less effective than oral therapy and is not recommended by the CDC 3, 1, 2
• Avoid valacyclovir 8 grams per day in immunocompromised patients due to risk of hemolytic uremic syndrome/thrombotic thrombocytopenic purpura 3
• If lesions do not begin to resolve within 7-10 days of therapy, suspect acyclovir resistance and consider foscarnet 40 mg/kg IV every 8 hours 3
• Delaying treatment beyond 72 hours for recurrences significantly reduces efficacy 2

Essential Patient Counseling

• Genital herpes is a recurrent, incurable viral disease; antivirals control symptoms but do not eradicate the virus 3, 1
• Abstain from sexual activity when lesions or prodromal symptoms are present 3, 1
• Inform sex partners about having genital herpes 3, 1
• Use condoms during all sexual exposures with new or uninfected partners 3, 1
• Asymptomatic viral shedding can occur and lead to transmission, particularly with HSV-2 infection 3, 1
• HSV-1 causes 5-30% of first-episode genital herpes cases but has much less frequent clinical recurrences than HSV-2 1

Special Populations

Pregnancy

• Routine suppressive therapy is not recommended during pregnancy for recurrent genital herpes 3
• Pregnant women should inform healthcare providers about HSV infection due to risk of neonatal transmission 1, 2
• The safety of systemic acyclovir and valacyclovir in pregnancy has not been definitively established, though acyclovir appears to be safe 3, 4

HIV-Infected Patients

• Higher dosages may be required in immunocompromised patients 1
• Antiviral resistance is more common in immunocompromised individuals 1
• Continue highly active antiretroviral therapy (HAART) alongside antiviral treatment 4