What is the recommended treatment for genital herpes?

Treatment of Genital Herpes

For first-episode genital herpes, treat with valacyclovir 1 g orally twice daily for 7-10 days, and for recurrent episodes, use valacyclovir 500 mg orally twice daily for 3-5 days starting at the first sign of symptoms. 1

First Clinical Episode

Initial treatment regimens recommended by the CDC include: 1

• Valacyclovir 1 g orally twice daily for 7-10 days (preferred for convenience)
• Acyclovir 400 mg orally three times daily for 7-10 days
• Acyclovir 200 mg orally five times daily for 7-10 days
• Famciclovir 250 mg orally three times daily for 7-10 days

Key treatment principles:

• Therapy is most effective when initiated within 48 hours of symptom onset 1
• Treatment may be extended beyond 10 days if healing is incomplete 1
• Higher acyclovir doses may be required for severe cases, particularly in immunocompromised patients 1

Recurrent Episodes (Episodic Therapy)

Episodic treatment options for recurrent genital herpes include: 1

• Valacyclovir 500 mg orally twice daily for 3 days (shortest FDA-approved course) 2
• Valacyclovir 500 mg orally twice daily for 5 days 3, 1
• Acyclovir 400 mg orally three times daily for 5 days 3, 1
• Acyclovir 800 mg orally twice daily for 5 days 1
• Famciclovir 125 mg orally twice daily for 5 days 3, 1
• Famciclovir 1000 mg orally twice daily for 1 day (single-day option) 4

Critical timing considerations:

• Treatment must be initiated during the prodrome or within 24 hours of lesion onset for maximum effectiveness 3, 1
• Patients should be provided with medication or a prescription to self-initiate treatment at the first sign of prodromal symptoms 1
• Delaying treatment beyond 72 hours significantly reduces efficacy 3

Suppressive Therapy

Daily suppressive therapy is recommended for patients with ≥6 recurrences per year, reducing recurrence frequency by ≥75%: 3, 1

• Valacyclovir 1 g orally once daily (standard dose) 1
• Valacyclovir 500 mg orally once daily (alternative for patients with <10 episodes/year) 3, 1
• Acyclovir 400 mg orally twice daily 1
• Famciclovir 250 mg orally twice daily 1, 4

Important suppressive therapy considerations:

• Valacyclovir 500 mg once daily may be less effective in patients with very frequent recurrences (≥10 episodes per year) 3
• Safety and efficacy documented for acyclovir up to 6 years and for valacyclovir/famciclovir for 1 year 1
• After 1 year of continuous suppressive therapy, consider discontinuation to reassess recurrence frequency 1

Special Populations

HIV-Infected Patients

• Famciclovir 500 mg orally twice daily for 7 days for recurrent episodes (reflecting increased viral replication) 1, 4
• Valacyclovir 500 mg orally twice daily for chronic suppression in patients with CD4+ count ≥100 cells/mm³ 3

Immunocompromised Patients

• Higher doses required: acyclovir 400 mg orally three to five times daily until clinical resolution 1
• For severe disease requiring hospitalization: acyclovir 5-10 mg/kg IV every 8 hours for 5-7 days 1
• If lesions persist despite acyclovir treatment, suspect viral resistance and consider foscarnet 40 mg/kg IV every 8 hours 1

Pregnant Women

• Oral acyclovir may be used during pregnancy, though safety data remain limited 1
• Women receiving acyclovir or valacyclovir during pregnancy should be reported to the manufacturer's pregnancy registry 1
• Pregnant women must inform their healthcare providers about HSV infection 1

HSV-1 vs HSV-2 Considerations

HSV-1 causes 5-30% of first-episode genital herpes cases but has much less frequent clinical recurrences than HSV-2: 1

• Identification of the infecting strain has prognostic importance and is useful for counseling 1
• Asymptomatic viral shedding occurs less frequently with HSV-1 than HSV-2 3, 1
• Treatment regimens are the same regardless of viral type 3, 1

Critical Pitfalls to Avoid

Topical acyclovir is substantially less effective than oral therapy and should NOT be used 3, 1

Other important considerations:

• Antiviral resistance is rare in immunocompetent patients but more common in immunocompromised individuals 1
• Valacyclovir and famciclovir offer more convenient dosing schedules compared to acyclovir while maintaining comparable clinical outcomes 3
• Treatment beyond 6 hours of symptom onset for recurrences has not been established as effective 4

Patient Counseling Requirements

Essential counseling points mandated by the CDC and ACOG: 1

• Inform patients about the chronic nature of HSV infection and potential for recurrence
• Counsel on asymptomatic viral shedding and sexual transmission risk
• Advise abstinence from sexual activity when lesions or prodromal symptoms are present
• Recommend condom use during all sexual exposures with new or uninfected partners
• Discuss the risk of neonatal infection, especially for childbearing-aged women
• Explain that antiviral medications control symptoms but do not eradicate the virus or prevent all recurrences
• Instruct patients to inform sexual partners about their HSV infection