Treatment Recommendation for HSV-2 on Buttocks
For a 69-year-old healthy woman with HSV-2 on the buttocks, valacyclovir is the preferred treatment due to superior bioavailability, less frequent dosing (improving adherence), and equivalent efficacy to acyclovir. 1, 2
Recommended Treatment Regimen
For Episodic Treatment (First Episode or Recurrence)
- Valacyclovir 500 mg orally twice daily for 5 days is the CDC-recommended episodic therapy for recurrent HSV infections 1
- Treatment must be initiated during the prodrome or within 1 day after onset of lesions for maximum benefit 1
- Alternative regimens if valacyclovir is unavailable include acyclovir 400 mg orally three times daily for 5 days, acyclovir 800 mg orally twice daily for 5 days, or acyclovir 200 mg orally five times daily for 5 days 1
Valacyclovir Advantages Over Acyclovir
- Valacyclovir provides 3-5 times greater oral bioavailability than acyclovir, allowing less frequent dosing 2, 3
- The twice-daily dosing of valacyclovir versus five-times-daily dosing of acyclovir significantly improves patient adherence 4, 5
- Clinical trials demonstrate equivalent efficacy between valacyclovir and acyclovir for HSV treatment, with similar tolerability profiles 4, 3
Suppressive Therapy Consideration
When to Consider Daily Suppression
- Discuss daily suppressive therapy if the patient experiences ≥6 recurrences per year 1
- Suppressive regimens include valacyclovir 500 mg orally once daily or valacyclovir 1 gram orally once daily 1
- Suppressive therapy reduces recurrence frequency by ≥75% and is safe for up to 1 year with valacyclovir 1
- In immunocompetent adults, valacyclovir 1 gram once daily resulted in 55% of patients remaining recurrence-free at 6 months versus only 7% with placebo 6
Critical Treatment Pitfalls to Avoid
- Topical acyclovir is substantially less effective than oral therapy and should not be used 1, 7
- Provide the patient with a prescription or medication supply to enable self-initiation at the first sign of prodrome or lesions in future episodes 1
- Antiviral medications control symptoms but do not eradicate the virus or prevent all recurrences 1
- Asymptomatic viral shedding can still occur, potentially leading to transmission 1
Patient Education Points
- Keep medication on hand for future episodes to enable immediate treatment at prodrome onset 1
- HSV-2 genital/perigenital infections (including buttocks) typically have more frequent recurrences than HSV-1 orolabial infections 1
- Treatment is most effective when started early, ideally during prodrome or within 24 hours of lesion onset 1
Special Considerations for This Patient
- At age 69, this patient is immunocompetent and healthy, so standard dosing applies without need for dose escalation 1
- No renal dose adjustment is needed unless there is underlying renal impairment 7
- The buttocks location represents genital/perigenital HSV-2, which follows the same treatment guidelines as genital herpes 1