What is the recommended treatment regimen for episodic herpes type 2 (Herpes Simplex Virus type 2) outbreaks?

Episodic Treatment for Herpes Type 2

For episodic treatment of recurrent genital HSV-2, initiate valacyclovir 500 mg orally twice daily for 5 days at the first sign of prodrome or within 24 hours of lesion onset. 1

First-Line Treatment Regimens

The CDC recommends the following episodic antiviral options for recurrent genital herpes 1:

• Valacyclovir 500 mg orally twice daily for 5 days - preferred for convenience and efficacy 1
• Acyclovir 400 mg orally three times daily for 5 days 1
• Acyclovir 800 mg orally twice daily for 5 days 1
• Acyclovir 200 mg orally five times daily for 5 days 1
• Famciclovir 125 mg orally twice daily for 5 days 1

Shortened Treatment Courses

For patients seeking maximum convenience, shorter regimens have proven equivalent efficacy 1:

• Valacyclovir 500 mg twice daily for 3 days is as effective as the 5-day course, with median healing times of 4.4 days versus 4.7 days 2
• Famciclovir 1000 mg twice daily for 1 day (single-day therapy) is noninferior to 3-day valacyclovir, with median healing time of 4.25 days 3

Critical Timing for Maximum Efficacy

Treatment must be initiated during the prodrome or within 1 day of lesion onset to achieve maximum benefit 1:

• Early treatment can abort lesions entirely in approximately 25-33% of patients 3, 2
• Delaying treatment beyond 72 hours significantly reduces effectiveness 4
• Patients should be provided with a prescription to self-initiate treatment at the first sign of recurrence 4

When Episodic Therapy Is Appropriate

Episodic therapy is most suitable for 1:

• Patients with infrequent recurrences (fewer than 6 episodes per year) 1
• Patients who can reliably recognize prodromal symptoms 1
• Situations where transmission prevention is not the primary concern 5

When to Consider Suppressive Therapy Instead

Switch to daily suppressive therapy if patients experience ≥6 recurrences per year 1:

• Suppressive therapy reduces recurrence frequency by ≥75% 1, 6
• Options include valacyclovir 500 mg or 1 g once daily, acyclovir 400 mg twice daily, or famciclovir 250 mg twice daily 1
• Suppressive therapy also reduces asymptomatic viral shedding and transmission risk 1

Important Clinical Pitfalls to Avoid

• Never use topical acyclovir - it is substantially less effective than oral therapy 1
• Do not delay prescribing episodic medication until an outbreak occurs; patients need medication on hand to self-initiate treatment immediately 4
• Most immunocompetent patients with recurrent disease do not benefit from treatment if initiated more than 2 days after lesion onset 7
• For patients with persistent symptoms beyond 5 days, consider extended treatment and evaluate for potential co-infections 1

Renal Dosing Adjustments

For patients with renal impairment, adjust acyclovir dosing based on creatinine clearance 8:

• CrCl >10 mL/min: 200 mg every 4 hours (5 times daily)
• CrCl 0-10 mL/min: 200 mg every 12 hours
• For hemodialysis patients: administer an additional dose after each dialysis session 8

Patient Counseling Essentials

Counsel all patients on 1:

• Abstaining from sexual activity when lesions or prodromal symptoms are present 1
• Using condoms during all sexual exposures, as asymptomatic viral shedding can occur even without visible lesions 1
• The chronic, recurrent nature of HSV-2 infection - antiviral medications control symptoms but do not eradicate the virus 1
• Informing sex partners about their HSV-2 status 1
• For women of childbearing age: informing prenatal care providers about their genital herpes history 7

Antiviral Resistance Considerations

• Resistance is rare in immunocompetent patients 1
• Suspect resistance if lesions do not begin to resolve within 7-10 days of therapy 1
• For proven or suspected resistance, foscarnet 40 mg/kg IV every 8 hours is the alternative 1
• Single-day famciclovir therapy does not increase resistance development compared to longer courses 5