Treatment of Genital Herpes in Females with Drainage from Lesions
For females with genital herpes presenting with drainage from lesions, initiate oral antiviral therapy immediately with one of three first-line regimens: acyclovir 400 mg three times daily for 7-10 days, valacyclovir 1 g twice daily for 7-10 days, or famciclovir 250 mg three times daily for 7-10 days. 1
Understanding the Clinical Context
Drainage from genital herpes lesions represents the vesicular or ulcerative stage of active infection, when viral shedding is at its peak and transmission risk is highest. 2 The presence of drainage does not alter the fundamental treatment approach but underscores the urgency of initiating antiviral therapy.
First-Line Treatment Regimens
For a first clinical episode (which appears most likely given the emphasis on drainage/active lesions), the CDC recommends three equally effective options: 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
- Valacyclovir 1 g orally twice daily for 7-10 days 1, 3
- Famciclovir 250 mg orally three times daily for 7-10 days 1, 4
Treatment should be extended beyond 10 days if complete healing has not occurred, as lesions may continue to shed virus until fully crusted. 1
Critical Treatment Principles
Topical acyclovir is substantially less effective than oral therapy and should NOT be used, despite older data suggesting some benefit. 1 Modern guidelines uniformly reject topical therapy for genital herpes. 1
Initiate treatment immediately upon diagnosis—do not wait for laboratory confirmation if clinical suspicion is high. 1 The efficacy of antiviral therapy is greatest when started early in the disease course. 5
Recurrent Episodes vs. First Episode
If this represents a recurrent episode rather than first infection, shorter treatment courses are appropriate: 1
- Valacyclovir 500 mg twice daily for 5 days 1
- Acyclovir 400 mg three times daily for 5 days 1
- Acyclovir 800 mg twice daily for 5 days 1
- Famciclovir 125 mg twice daily for 5 days 1
Episodic therapy is most effective when initiated during prodrome or within 1 day of lesion onset. 1 Patients should be provided with medication in advance to self-initiate at the first sign of recurrence. 1
Suppressive Therapy Consideration
For patients experiencing frequent recurrences (≥6 episodes per year), daily suppressive therapy reduces recurrence frequency by ≥75%: 1
- Valacyclovir 1 g once daily 1
- Valacyclovir 500 mg once daily 1
- Acyclovir 400 mg twice daily 1
- Famciclovir 250 mg twice daily 1
After 1 year of continuous suppressive therapy, consider discontinuation to reassess recurrence frequency. 1
Special Populations Requiring Modified Dosing
Immunocompromised Patients
Higher doses are required for immunocompromised patients, such as acyclovir 400 mg orally three to five times daily until clinical resolution. 6 For severe disease requiring hospitalization, intravenous acyclovir 5-10 mg/kg every 8 hours for 5-7 days is indicated. 1
If lesions persist despite acyclovir treatment, suspect viral resistance and consider foscarnet 40 mg/kg IV every 8 hours. 6
HIV-Infected Patients
For HIV-infected patients with recurrent genital herpes, famciclovir 500 mg twice daily for 7 days is recommended. 4 This higher dose and longer duration compared to immunocompetent patients reflects increased viral replication in this population. 6
Pregnant Women
The first clinical episode during pregnancy may be treated with oral acyclovir, though safety data remain limited. 6 Women receiving acyclovir or valacyclovir during pregnancy should be reported to the manufacturer's pregnancy registry. 6
Antiviral prophylaxis with acyclovir from 36 weeks gestation until delivery is recommended for pregnant women with a history of genital herpes to reduce the risk of active lesions at delivery and neonatal transmission. 2
Renal Impairment
Dose adjustments are mandatory for patients with renal impairment to prevent acute renal failure. 4 For creatinine clearance 40-59 mL/min, reduce famciclovir to 500 mg every 12 hours; for CrCl 20-39 mL/min, reduce to 500 mg every 24 hours. 4
Essential Patient Counseling
Patients must be counseled to abstain from sexual activity when lesions or prodromal symptoms are present, as this is when transmission risk is highest. 1 However, asymptomatic viral shedding occurs frequently (more common with HSV-2 than HSV-1), so transmission can occur even without visible lesions. 1
Condoms should be used during all sexual exposures with new or uninfected partners, though they do not provide complete protection. 1
Patients should inform sex partners about having genital herpes and understand that antiviral medications control symptoms but do not eradicate the virus or prevent all recurrences. 1
Common Pitfalls to Avoid
Do not use inadequate treatment duration—continue therapy until all lesions have completely crusted, not just for an arbitrary 7-day period if healing is incomplete. 1
Do not prescribe topical acyclovir, which is substantially less effective than oral therapy despite older literature suggesting benefit. 1, 7
Do not fail to adjust doses for renal impairment, as inappropriately high doses have caused acute renal failure in patients with underlying kidney disease. 4
Do not assume HSV-1 genital herpes behaves identically to HSV-2—HSV-1 causes 5-30% of first-episode genital herpes but has much less frequent clinical recurrences, which has important prognostic implications for counseling. 1