What is the recommended treatment for a patient with vaginal herpes?

Treatment of Vaginal Herpes

For first-episode vaginal herpes, initiate valacyclovir 1 g orally twice daily for 7-10 days, starting within 48 hours of symptom onset for maximum effectiveness. 1

First Clinical Episode

Recommended antiviral regimens for initial genital herpes include: 1

• Valacyclovir 1 g orally twice daily for 7-10 days (preferred for convenient dosing) 1, 2
• Acyclovir 400 mg orally three times daily for 7-10 days 1
• Acyclovir 200 mg orally five times daily for 7-10 days 1
• Famciclovir 250 mg orally three times daily for 7-10 days 1

Treatment should be initiated within 48 hours of symptom onset for optimal efficacy, though later initiation still provides benefit. 1, 2 Extend therapy beyond 10 days if healing remains incomplete. 1

Avoid topical acyclovir entirely—it is substantially less effective than oral therapy and should not be used. 1, 3

Recurrent Episodes

For recurrent outbreaks, prescribe episodic therapy to be self-initiated at the first sign of prodrome or within 24 hours of lesion onset: 1

• Valacyclovir 500 mg orally twice daily for 3-5 days (FDA-approved 3-day regimen available) 1, 2
• Acyclovir 400 mg orally three times daily for 5 days 1
• Acyclovir 800 mg orally twice daily for 5 days 1
• Famciclovir 125 mg orally twice daily for 5 days 1

Provide patients with a prescription or medication supply to keep on hand for immediate self-initiation at symptom onset, as treatment effectiveness decreases dramatically after the first 24 hours. 1, 4

Suppressive Therapy

Initiate daily suppressive therapy for patients experiencing ≥6 recurrences per year: 1, 3

• Valacyclovir 1 g orally once daily (preferred for once-daily dosing) 1, 2
• Valacyclovir 500 mg orally once daily (alternative for patients with ≤9 recurrences/year) 1, 2
• Acyclovir 400 mg orally twice daily 1
• Famciclovir 250 mg orally twice daily 1

Suppressive therapy reduces recurrence frequency by ≥75% and decreases asymptomatic viral shedding, thereby reducing transmission risk. 1, 3 Safety has been documented for acyclovir up to 6 years and valacyclovir/famciclovir for 1 year. 1 After 1 year of continuous suppression, consider discontinuing therapy to reassess recurrence frequency. 1, 3

Severe Disease

For severe disease requiring hospitalization or complications, administer acyclovir 5-10 mg/kg IV every 8 hours for 5-7 days or until clinical resolution. 1 Immunocompromised patients may require higher oral doses (400 mg three to five times daily) or IV therapy. 1

Suspect acyclovir resistance if lesions fail to improve within 7-10 days of therapy, particularly in immunocompromised patients; consider foscarnet 40 mg/kg IV every 8 hours. 1, 3

Critical Patient Counseling

Counsel all patients on the following essential points: 1

• Genital herpes is a chronic, incurable infection with potential for lifelong recurrence 1
• Antiviral medications control symptoms but do not eradicate the virus or prevent all recurrences 1
• Abstain from sexual activity when lesions or prodromal symptoms are present 1
• Inform all sexual partners about the herpes diagnosis 1
• Use condoms during all sexual exposures with new or uninfected partners, though transmission can still occur during asymptomatic viral shedding 1
• Asymptomatic viral shedding occurs more frequently with HSV-2 than HSV-1 and in the first 12 months after infection 1
• Women of childbearing age should inform healthcare providers about herpes infection if pregnant 1

Special Populations

For HIV-infected patients with CD4+ counts ≥100 cells/mm³, use valacyclovir 500 mg twice daily for suppressive therapy. 1, 2 HIV-infected patients with recurrent episodes may require famciclovir 500 mg twice daily for 7 days due to increased viral replication. 1

For pregnant women, oral acyclovir may be used for first episodes, though safety data remain limited. 1 Report all acyclovir or valacyclovir use during pregnancy to the manufacturer's pregnancy registry. 1 Routine suppressive therapy during pregnancy is not recommended for recurrent herpes. 3

Common Pitfalls to Avoid

• Never use topical acyclovir—it is substantially less effective than oral therapy 1, 4, 3
• Do not delay treatment beyond 24-72 hours for recurrent episodes, as efficacy decreases significantly 4
• Avoid valacyclovir 8 g/day in immunocompromised patients due to risk of hemolytic uremic syndrome/thrombotic thrombocytopenic purpura 3
• Do not assume HSV-2—HSV-1 causes 5-30% of first-episode genital herpes and has different recurrence patterns; type-specific testing has prognostic value 1