What is the treatment for a patient with recurrent genital herpes?

Treatment of Recurrent Genital Herpes

For recurrent genital herpes, initiate episodic antiviral therapy with valacyclovir 500 mg orally twice daily for 5 days, starting at the first sign of prodrome or within 24 hours of lesion onset, or switch to daily suppressive therapy with valacyclovir 1 gram once daily if experiencing 6 or more recurrences per year. 1, 2

Episodic Treatment for Recurrent Episodes

Preferred regimen:

• Valacyclovir 500 mg orally twice daily for 5 days 1, 2, 3

Alternative regimens (all equally effective):

• Acyclovir 400 mg orally three times daily for 5 days 1, 2
• Acyclovir 800 mg orally twice daily for 5 days 1
• Acyclovir 200 mg orally five times daily for 5 days 1
• Famciclovir 125 mg orally twice daily for 5 days 1, 2

Critical timing consideration:

• Treatment must be initiated during the prodrome or within 24 hours of lesion onset for maximum efficacy 1, 2
• Efficacy drops significantly if treatment starts after 24 hours of symptom onset 2
• Provide patients with a prescription to self-initiate at first symptoms rather than waiting for an office visit 4

Suppressive Therapy for Frequent Recurrences

Indications:

• 6 or more recurrences per year 1, 2, 3

Preferred regimen:

• Valacyclovir 1 gram orally once daily 1, 2, 3

Alternative regimens:

• Valacyclovir 500 mg orally once daily (may be less effective in patients with ≥10 episodes per year) 1, 4
• Acyclovir 400 mg orally twice daily 1, 2
• Famciclovir 250 mg orally twice daily 1, 2

Efficacy and safety:

• Suppressive therapy reduces recurrence frequency by ≥75% 5, 1, 2
• Safe for extended use: up to 6 years with acyclovir and at least 1 year with valacyclovir 1
• After 1 year of suppressive therapy, consider discontinuation to reassess recurrence frequency 1

Critical Pitfalls to Avoid

Do NOT use topical acyclovir:

• Topical acyclovir is substantially less effective than oral therapy and should be avoided 5, 1, 2, 4

Suspect acyclovir resistance if:

• Lesions fail to resolve within 7-10 days of therapy 1, 2
• Resistance is rare in immunocompetent patients but more common in immunocompromised individuals 2
• For proven or suspected resistance, use foscarnet 40 mg/kg IV every 8 hours 1, 2

Special warning for immunocompromised patients:

• Avoid valacyclovir 8 grams per day—associated with hemolytic uremic syndrome/thrombotic thrombocytopenic purpura in this population 1, 2

Patient Counseling Essentials

Disease education:

• Genital herpes is a recurrent, incurable viral disease 1, 2
• Antiviral medications control symptoms but do not eradicate the virus or prevent all recurrences 1, 2
• HSV-2 causes more frequent recurrences than HSV-1 5

Transmission prevention:

• Abstain from sexual activity when lesions or prodromal symptoms are present 5, 1, 2
• Use condoms during all sexual exposures with new or uninfected partners 5, 2
• Asymptomatic viral shedding can occur and lead to transmission even without visible lesions 5, 1, 2
• Asymptomatic shedding occurs more frequently in the first 12 months after infection 5

Pregnancy considerations:

• Inform healthcare providers about HSV infection during pregnancy 5
• Routine suppressive therapy is not recommended during pregnancy for recurrent genital herpes 1

Follow-Up Management

• Extend treatment beyond 5 days if symptoms persist 1, 2
• Evaluate for potential co-infections if discharge and pelvic pain persist despite treatment 1
• Reassess need for suppressive therapy annually 1