Treatment of Recurrent HSV Infections
For recurrent genital herpes, treat with valacyclovir 500 mg orally twice daily for 5 days, or consider daily suppressive therapy with valacyclovir 1 gram once daily if the patient experiences 6 or more recurrences per year. 1, 2
Episodic Treatment for Recurrent Episodes
When to initiate: Treatment is most effective when started during the prodrome or within 1 day after onset of lesions 1, 2. Delayed treatment beyond 72 hours significantly reduces effectiveness 3, 1.
First-line options for recurrent episodes (5-day courses):
- Valacyclovir 500 mg orally twice daily - preferred due to convenient dosing 1, 2
- Acyclovir 400 mg orally three times daily 4, 1
- Acyclovir 800 mg orally twice daily 4, 1
- Acyclovir 200 mg orally five times daily 4, 1
- Famciclovir 125 mg orally twice daily 3, 1
Shorter course options: A 2-day regimen of acyclovir 800 mg three times daily has been shown to significantly reduce lesion duration (4 days vs 6 days with placebo) and viral shedding 5. However, the standard 5-day courses remain guideline-recommended 1, 2.
Daily Suppressive Therapy
Indications: Patients with frequent recurrences (≥6 episodes per year) 4, 1, 2
Benefits: Reduces recurrence frequency by ≥75%, decreases asymptomatic viral shedding, and reduces transmission risk to sexual partners 4, 1, 2
Recommended regimens:
- Valacyclovir 1 gram orally once daily (or 500 mg once daily for those with 9 or fewer recurrences per year) 1, 2, 6
- Acyclovir 400 mg orally twice daily 4, 1, 2
- Famciclovir 250 mg orally twice daily 3, 1, 2
Duration and reassessment: After 1 year of continuous suppressive therapy, discontinue to reassess the patient's recurrence rate 4, 1, 2. Safety and efficacy have been documented for up to 5-6 years 4, 2.
Special Populations
HIV-infected patients:
- May require longer treatment courses than HIV-negative patients 1
- Famciclovir 500 mg twice daily has been effective in reducing recurrences and subclinical shedding 3, 1
- Valacyclovir 500 mg twice daily for suppression showed 65% recurrence-free rate at 6 months versus 26% with placebo 6
Immunocompromised patients:
- Higher doses may be needed: acyclovir 400 mg orally 3-5 times daily until clinical resolution 3
- Monitor for acyclovir-resistant strains, which may require IV foscarnet 40 mg/kg every 8 hours 1, 2
Critical Clinical Considerations
What NOT to do:
- Avoid topical acyclovir - it is substantially less effective than oral therapy and is not recommended 4, 1, 2
- Do not use valacyclovir 8 grams per day in immunocompromised patients due to risk of hemolytic uremic syndrome/thrombotic thrombocytopenic purpura 2
Treatment failure: Suspect acyclovir resistance if lesions do not begin to resolve within 7-10 days of therapy 1, 2. Obtain viral culture with susceptibility testing and consider IV foscarnet for confirmed resistance 1, 2.
Monitoring: No laboratory monitoring is needed for patients on episodic or suppressive therapy unless significant renal impairment exists 1
Patient Counseling
Essential counseling points:
- Abstain from sexual activity when lesions or prodromal symptoms are present 4, 1, 2
- Use condoms consistently during all sexual exposures - reduces transmission risk by approximately 50% 1
- Asymptomatic viral shedding can occur, potentially leading to transmission even without visible lesions 4, 1, 2
- Antiviral medications control symptoms but do not eradicate latent virus or prevent all future recurrences 4, 2
- Women of childbearing age should inform healthcare providers about HSV infection during pregnancy 4