Treatment for First-Time HSV Outbreak
For a first clinical episode of genital herpes, treat with valacyclovir 1 gram orally twice daily for 7-10 days, which is the preferred first-line therapy recommended by the CDC. 1
First-Line Treatment Options
The CDC recommends longer treatment courses for first episodes compared to recurrent outbreaks, with any of the following regimens: 1
- Valacyclovir 1 g orally twice daily for 7-10 days (preferred due to convenient dosing) 1
- Acyclovir 400 mg orally three times daily for 7-10 days 1
- Acyclovir 200 mg orally five times daily for 7-10 days 1
- Famciclovir 250 mg orally three times daily for 7-10 days 1
Treatment may be extended beyond 10 days if healing is incomplete. 1
Critical Timing Considerations
- Initiate treatment as soon as possible after symptom onset, ideally within 72 hours 1
- Treatment is most effective when started during the prodromal period or within 1 day after onset of lesions 1
- Delayed treatment beyond 72 hours significantly reduces effectiveness 1
What NOT to Do: Common Pitfalls
Avoid topical acyclovir—it is substantially less effective than systemic therapy and is not recommended. 1, 2 This is a critical error that significantly compromises treatment outcomes.
Clinical Efficacy Data
In clinical trials of 643 immunocompetent adults with first-episode genital herpes, both valacyclovir 1 gram twice daily and acyclovir 200 mg five times daily for 10 days showed: 3
- Median time to lesion healing: 9 days
- Median time to cessation of pain: 5 days
- Median time to cessation of viral shedding: 3 days
Special Populations
HIV-Infected Patients
- Require close monitoring and may need longer treatment courses than HIV-negative patients 1
- Famciclovir 500 mg twice daily has been effective in reducing recurrences and subclinical shedding in this population 1
Pregnant Women
- Safety considerations are important, though systemic acyclovir and valacyclovir safety in pregnancy has not been definitively established 4
Essential Patient Counseling
Patients must understand: 1, 4
- Genital herpes is a chronic, incurable viral disease
- Antiviral medications control symptoms but do not eradicate latent virus
- Recurrences are common after initial infection, particularly with HSV-2
- Abstain from sexual activity when lesions or prodromal symptoms are present
- Asymptomatic viral shedding can occur, potentially leading to transmission
- Consistent condom use reduces transmission risk by approximately 50% 1
Planning for Future Recurrences
Provide a prescription for antiviral medication at the initial visit so patients can self-initiate treatment at the first sign of recurrence. 2 This patient-initiated episodic therapy (PIE) approach allows treatment within the narrow therapeutic window early in the episode when it is most effective. 5
For recurrent episodes, shorter 5-day courses are appropriate (e.g., valacyclovir 500 mg twice daily for 5 days). 1, 4
When to Consider Suppressive Therapy
After the initial episode, consider daily suppressive therapy if the patient experiences ≥6 recurrences per year: 1, 4
- Valacyclovir 1 g orally once daily or 500 mg once daily
- Acyclovir 400 mg orally twice daily
- Famciclovir 250 mg orally twice daily
Suppressive therapy can reduce recurrence frequency by ≥75% and reduce asymptomatic viral shedding. 1, 4
Treatment Failure Considerations
If symptoms persist beyond expected healing time (7-10 days), suspect: 1
- Incorrect diagnosis
- Co-infection with another STD
- HIV infection
- Poor medication adherence
- Acyclovir resistance (rare in immunocompetent patients but more common in immunocompromised hosts) 6
For confirmed acyclovir-resistant HSV, use IV foscarnet 40 mg/kg every 8 hours. 1, 4, 6
Monitoring Requirements
No laboratory monitoring is needed for patients on episodic therapy unless substantial renal impairment exists. 1 Common side effects include nausea and headache. 1