Treatment for Initial Episode of Genital Herpes
For the initial episode of genital herpes, prescribe valacyclovir 1 gram orally twice daily for 10 days, initiated within 48 hours of symptom onset for maximum efficacy. 1, 2
First-Line Treatment Regimen
Valacyclovir 1 gram orally twice daily for 10 days is the preferred treatment for initial genital herpes, as recommended by the CDC and FDA. 1, 2
Treatment is most effective when started within 48 hours of the onset of signs and symptoms, though it should be initiated as soon as possible regardless of timing. 1, 2
The 10-day duration applies to both HSV-1 and HSV-2 genital infections. 1
If healing is incomplete after 10 days, extend treatment beyond the standard duration until lesions have fully resolved. 1
Alternative Treatment Options
Acyclovir 400 mg orally three times daily for 7-10 days is an effective alternative if valacyclovir is unavailable or cost is prohibitive. 1
Acyclovir 200 mg orally five times daily for 5 days is another option, though the more frequent dosing may reduce adherence. 3
Clinical trials demonstrate that valacyclovir and acyclovir have equivalent efficacy for initial episodes, with median time to lesion healing of 9 days, cessation of pain at 5 days, and cessation of viral shedding at 3 days for both agents. 2, 4
Critical Pitfalls to Avoid
Never use topical acyclovir alone for genital herpes—it is substantially less effective than systemic therapy and does not improve systemic symptoms. 1, 3
Do not delay treatment waiting for laboratory confirmation in typical presentations; initiate therapy based on clinical diagnosis. 5
Intravenous acyclovir should be reserved for complicated episodes, such as disseminated disease, CNS involvement, or severe immunocompromise. 3
Essential Patient Counseling at Initial Visit
Inform patients that genital herpes is a chronic, incurable viral infection that will remain latent and can recur throughout life. 1
Explain that antiviral treatment controls symptoms and reduces viral shedding but does not eradicate the virus or prevent all future recurrences. 1
Counsel patients to abstain from sexual activity when lesions or prodromal symptoms are present. 1
Discuss the risk of asymptomatic viral shedding and potential transmission even without visible lesions. 1
Advise patients to inform current and future sexual partners about their herpes diagnosis. 1
Recommend consistent condom use during all sexual exposures with new or uninfected partners, though this does not eliminate transmission risk entirely. 1
Explain the risk of neonatal transmission to all patients, including men who may father children with infected partners. 1
Planning for Future Management
Provide a prescription for antiviral medication at the initial visit so patients can self-initiate treatment at the first sign of future recurrences (prodromal symptoms or within 24 hours of lesion onset). 1
Discuss that episodic treatment of recurrences is most effective when started during the prodromal period. 1
Inform patients that if they experience ≥6 recurrences per year, daily suppressive therapy should be considered, which can reduce recurrence frequency by ≥75%. 1
Special Considerations
Primary genital herpes (no preexisting antibody to either HSV type with subsequent seroconversion) typically has longer healing times, more prolonged viral shedding, and greater pain duration compared to nonprimary first episodes (preexisting HSV-1 antibody with new HSV-2 infection or vice versa). 4, 5
First-episode genital herpes tends to be more severe in women than men, with higher rates of local and distant complications. 5
In immunocompromised patients, complications may be life-threatening and require more aggressive management with intravenous therapy. 3, 5