What is the treatment for genital Herpes Simplex Virus (HSV) lesions?

Treatment of Genital HSV Lesions

For recurrent genital herpes, start valacyclovir 500 mg orally twice daily for 5 days at the first sign of symptoms, or consider suppressive therapy with valacyclovir 1 gram once daily if experiencing 6 or more episodes per year. 1, 2

First Episode (Initial Infection)

• Acyclovir 200 mg orally 5 times daily for 7-10 days until clinical resolution is the CDC-recommended treatment for first clinical episodes 2
• Alternative regimens include acyclovir 400 mg orally 5 times daily for 10 days, particularly for herpes proctitis 2
• Valacyclovir 1 gram twice daily for 10 days is equally effective, with the median time to lesion healing being 9 days in clinical trials 3
• Severe disease requiring hospitalization (disseminated infection, pneumonitis, hepatitis, CNS complications) necessitates IV acyclovir 5-10 mg/kg every 8 hours for 5-7 days 4, 2

Recurrent Episodes: Episodic Treatment

Timing is critical—treatment must begin during prodrome or within 1 day of lesion onset for maximum effectiveness. 1

First-Line Options:

• Valacyclovir 500 mg orally twice daily for 5 days is the preferred CDC recommendation 1, 2
• Famciclovir 1000 mg twice daily for 1 day (single-day therapy) reduces median healing time from 6.1 to 4.3 days and increases aborted lesions from 13% to 23% 5

Alternative Regimens:

• Acyclovir 400 mg orally three times daily for 5 days 1, 2
• Acyclovir 800 mg orally twice daily for 5 days 1, 2
• Acyclovir 200 mg orally five times daily for 5 days 4, 1
• Famciclovir 125 mg orally twice daily for 5 days 4, 1

A 2-day course of acyclovir 800 mg three times daily significantly reduces lesion duration (4 vs 6 days) and viral shedding (25 vs 58.5 hours) compared to placebo, offering a convenient shorter alternative. 6

Suppressive Therapy (≥6 Recurrences Per Year)

Daily suppressive therapy reduces recurrence frequency by ≥75% and is safe for extended use. 1, 2

Recommended Regimens:

• Valacyclovir 1 gram orally once daily (preferred for most patients) 1, 2
• Valacyclovir 500 mg orally once daily (less effective if ≥10 episodes/year) 4, 1
• Acyclovir 400 mg orally twice daily 4, 1, 2
• Famciclovir 250 mg orally twice daily 4, 1, 2

Clinical trials demonstrate 34% of patients remain recurrence-free at 12 months on valacyclovir 1 gram daily versus only 4% on placebo. 3

• After 1 year of suppressive therapy, consider discontinuation to reassess recurrence frequency 1
• Suppressive therapy is safe for up to 6 years with acyclovir and 1 year with valacyclovir based on documented safety data 1

Special Populations

HIV-Infected/Immunocompromised Patients:

• Higher doses are required: acyclovir 400 mg orally 3-5 times daily until clinical resolution 4
• Famciclovir 500 mg twice daily is effective for decreasing recurrences and subclinical shedding 4
• For HIV-infected patients with stable antiretroviral therapy, valacyclovir 500 mg twice daily for 6 months results in 65% remaining recurrence-free versus 26% on placebo 3
• Severe cases require IV acyclovir 5 mg/kg every 8 hours 4
• Critical warning: Valacyclovir 8 grams per day is associated with hemolytic uremic syndrome/thrombotic thrombocytopenic purpura in immunocompromised patients and must be avoided 1

Acyclovir Resistance:

• Suspect resistance if lesions fail to resolve within 7-10 days of therapy 1
• Resistance is rare in immunocompetent patients but more common in immunocompromised individuals 4, 2
• Foscarnet 40 mg/kg IV every 8 hours is the treatment for proven or suspected acyclovir resistance 1

Critical Clinical Pitfalls

• Topical acyclovir is substantially less effective than oral therapy and should not be used, despite older studies suggesting benefit 1, 2, 7
• Treatment initiated after 24 hours of symptom onset has significantly reduced efficacy 1
• Valacyclovir and famciclovir offer comparable efficacy to acyclovir but with improved dosing convenience for prolonged treatment 4
• Routine suppressive therapy is not recommended during pregnancy, though safety data for acyclovir and valacyclovir in pregnancy is reassuring 1

Patient Counseling Essentials

• Genital herpes is a recurrent, incurable viral disease—antiviral medications control symptoms but do not eradicate the virus or prevent all recurrences 1, 2
• Abstain from sexual activity when lesions or prodromal symptoms are present 1, 2
• Use condoms during all sexual exposures with new or uninfected partners 1
• Asymptomatic viral shedding can occur and lead to transmission even without visible lesions 1, 2
• Persistent symptoms beyond 5 days warrant evaluation for treatment extension or potential co-infections 1