What is the treatment for a patient with herpes simplex virus (HSV) lesions on the buttocks?

SOAP Note: Herpes Lesions on Buttocks

Subjective

• Document onset and duration of lesions, presence of prodromal symptoms (tingling, burning, itching), and history of similar outbreaks 1
• Ask about frequency of recurrences per year to determine if suppressive therapy is warranted 1, 2
• Assess for systemic symptoms (fever, malaise, adenopathy) which suggest primary infection versus recurrence 3
• Inquire about HIV status and immunocompromised conditions, as these affect treatment duration and resistance risk 4, 5

Objective

• Examine for characteristic clustered vesicles or ulcerated lesions on buttocks, perineum, or perianal areas 3
• Document lesion stage (vesicular, ulcerated, crusted) and extent of involvement 4
• Check for inguinal lymphadenopathy 3
• Consider obtaining viral culture or PCR if diagnosis uncertain, especially for suspected acyclovir resistance if lesions persist beyond 7-10 days 4, 3

Assessment

Recurrent genital herpes simplex virus infection (buttocks distribution)

Plan

Treatment Recommendations

For episodic treatment of recurrent outbreaks, initiate oral valacyclovir 500 mg twice daily for 5 days, starting at the first sign of symptoms. 1

Alternative oral regimens include:

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

Treatment is most effective when started during prodrome or within 1 day of lesion onset. 1

Suppressive Therapy Consideration

If patient has ≥6 recurrences per year, recommend daily suppressive therapy with valacyclovir 1 g orally once daily (or 500 mg once daily as alternative). 1, 2

Alternative suppressive regimens:

• Acyclovir 400 mg twice daily 1, 2
• Famciclovir 250 mg twice daily 1, 2

Suppressive therapy reduces recurrence frequency by ≥75% and is safe for extended use (up to 6 years with acyclovir, 1 year documented with valacyclovir). 1

Special Considerations

• Do not use topical acyclovir—it is substantially less effective than oral therapy 4, 1, 6
• For severe disease requiring hospitalization: acyclovir 5-10 mg/kg IV every 8 hours for 5-7 days 2
• If lesions fail to improve within 7-10 days, suspect acyclovir resistance: obtain viral culture with susceptibility testing and consider IV foscarnet 40 mg/kg every 8 hours 4, 1, 5
• HIV-infected patients may require longer treatment courses and closer monitoring for resistance 4, 5

Patient Education

• Counsel that genital herpes is a chronic, incurable viral infection with potential for recurrence 1
• Advise abstinence from sexual activity when lesions or prodromal symptoms present 1, 2
• Inform about asymptomatic viral shedding and transmission risk even without visible lesions 1, 2
• Recommend consistent condom use with new or uninfected partners 4, 1
• Provide prescription for self-initiated treatment at first sign of future recurrences 6

Follow-Up

• Reassess if symptoms persist beyond 5 days of treatment 1
• After 1 year of suppressive therapy, consider discontinuation to reassess recurrence frequency 1
• Monitor for treatment failure or resistance development, particularly in immunocompromised patients 4, 5