Treatment of Genital Herpes
For initial genital herpes episodes, treat with valacyclovir 1 gram orally twice daily for 7-10 days, starting within 48 hours of symptom onset for maximum effectiveness. 1, 2
Initial Episode Management
First-line treatment options include:
- Valacyclovir 1 g orally twice daily for 7-10 days (preferred for convenience) 1, 2
- Acyclovir 400 mg orally three times daily for 7-10 days 1
- Famciclovir 250 mg orally three times daily for 7-10 days 1
Extend treatment beyond 10 days if healing is incomplete. 1 The CDC emphasizes that therapy is most effective when initiated within 48 hours of symptom onset. 1
Recurrent Episode Treatment
For recurrent outbreaks, use episodic therapy with valacyclovir 500 mg orally twice daily for 3-5 days, initiated at the first sign of prodrome or lesions. 3, 2
Alternative episodic regimens:
- Acyclovir 400 mg orally three times daily for 5 days 3
- Acyclovir 800 mg orally twice daily for 5 days 3
- Famciclovir 125 mg orally twice daily for 5 days 3
Critical timing: Start treatment during prodrome or within 24 hours of lesion onset, as peak viral replication occurs in the first 24 hours. 3, 1 A 3-day course of valacyclovir 500 mg twice daily is equivalent to 5 days in efficacy. 4
Provide patients with a prescription to self-initiate treatment at first symptoms. 3
Suppressive Therapy
Consider daily suppressive therapy for patients with ≥6 recurrences per year, which reduces recurrence frequency by ≥75%. 3, 1
Suppressive regimens:
- Valacyclovir 1 g orally once daily (standard dose) 3, 2
- Valacyclovir 500 mg orally once daily (for patients with <10 recurrences/year) 3, 5
- Acyclovir 400 mg orally twice daily 3
- Famciclovir 250 mg orally twice daily 3
For HIV-infected patients with CD4+ ≥100 cells/mm³, use valacyclovir 500 mg twice daily. 3 After 1 year of continuous suppressive therapy, consider discontinuation to reassess recurrence frequency. 3
Special Populations
Severe disease requiring hospitalization:
- Acyclovir 5-10 mg/kg IV every 8 hours for 5-7 days or until clinical resolution 1
Immunocompromised patients:
- Higher doses required: acyclovir 400 mg orally 3-5 times daily until clinical resolution 1
- If lesions persist after 7-10 days, suspect acyclovir resistance and use foscarnet 40 mg/kg IV every 8 hours 3, 1
Pregnancy:
- Same oral regimens can be used for initial or recurrent episodes 1, 6
- Prophylactic suppression after 36 weeks: acyclovir 400 mg three times daily or valacyclovir 500 mg twice daily until delivery 6
- Report valacyclovir/acyclovir use to manufacturer's pregnancy registry 1
Critical Counseling Points
Patients must understand:
- Genital herpes is chronic and incurable; antivirals control symptoms but don't eradicate the virus 3, 1
- Asymptomatic viral shedding occurs and can transmit infection 3, 1
- Abstain from sexual activity when lesions or prodromal symptoms present 3, 1
- Use condoms during all sexual exposures with new or uninfected partners 3, 1
- Inform sexual partners about HSV status 3, 1
- Risk of neonatal transmission exists, particularly important for women of childbearing age 1
Common Pitfalls to Avoid
Never use topical acyclovir alone—it is substantially less effective than oral therapy. 3, 1
Avoid valacyclovir 8 grams per day in immunocompromised patients due to risk of hemolytic uremic syndrome/thrombotic thrombocytopenic purpura. 3
Don't delay treatment beyond 24-72 hours for recurrences, as efficacy decreases significantly. 7, 3
HSV-1 vs HSV-2 distinction: HSV-1 causes 5-30% of genital herpes cases but recurs much less frequently than HSV-2, making strain identification valuable for prognosis and counseling. 1