What is the recommended management for a patient with genital herpes?

Management of Genital Herpes

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

Initial Episode Treatment

First-line therapy for the initial clinical episode of genital herpes consists of: 1

• 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

Critical timing considerations:

• Treatment is most effective when initiated within 48 hours of lesion onset 1
• Extend therapy beyond 10 days if healing remains incomplete 1
• Higher acyclovir dosages may be required for severe cases, particularly in immunocompromised patients 1

Recurrent Episodes: Episodic Therapy

For recurrent outbreaks, patients should self-initiate treatment during the prodrome or within 24 hours of lesion onset with one of the following regimens: 1

Preferred short-course options:

• Valacyclovir 500 mg orally twice daily for 3 days (most convenient, FDA-approved 3-day regimen) 1, 2
• Famciclovir 1000 mg orally twice daily for 1 day (single-day option) 3, 4
• Acyclovir 800 mg orally twice daily for 5 days 1

Alternative regimens:

• Acyclovir 400 mg orally three times daily for 5 days 1
• Famciclovir 125 mg orally twice daily for 5 days 1

Key management principles:

• Provide patients with a prescription or medication supply to self-initiate at first prodromal symptoms 1
• Single-day famciclovir (1000 mg twice daily) is noninferior to 3-day valacyclovir in healing time and prevents lesion progression in approximately one-third of patients 3, 4
• Treatment initiated during prodrome is significantly more effective than delayed therapy 1

Suppressive Therapy

Daily suppressive therapy should be considered for patients with ≥6 recurrences per year, which reduces recurrence frequency by ≥75%: 1

Recommended suppressive regimens:

• Valacyclovir 1 g orally once daily (standard dose) 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

Duration and monitoring:

• Safety and efficacy documented for acyclovir up to 6 years and valacyclovir/famciclovir for 1 year 1
• After 1 year of continuous suppressive therapy, consider discontinuation to reassess recurrence frequency 1
• Valacyclovir 500 mg once daily may be less effective in patients with very frequent recurrences (≥10 episodes per year) 5

Special Populations

HIV-infected patients with CD4+ ≥100 cells/mm³:

• Valacyclovir 500 mg orally twice daily for suppressive therapy 2
• Famciclovir 500 mg twice daily for 7 days for recurrent episodes 1

Severe disease requiring hospitalization:

• Acyclovir 5-10 mg/kg IV every 8 hours for 5-7 days or until clinical resolution 1

Pregnant women:

• Should inform healthcare providers about HSV infection 1
• 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

Immunocompromised patients:

• Higher doses of acyclovir (400 mg orally 3-5 times daily) may be required until clinical resolution 1
• If lesions persist despite acyclovir treatment, suspect viral resistance and consider foscarnet 40 mg/kg IV every 8 hours 1

Essential Patient Counseling

Disease education: 1

• Genital herpes is a chronic, incurable infection with potential for lifelong recurrence
• Asymptomatic viral shedding occurs more frequently with HSV-2 than HSV-1 and in patients with infection <12 months
• Antiviral medications control symptoms but do not eradicate the virus or prevent all recurrences

Transmission prevention: 1

• Abstain from sexual activity when lesions or prodromal symptoms are present
• Use condoms during all sexual exposures with new or uninfected partners
• Inform sexual partners about having genital herpes
• Transmission can occur during asymptomatic periods through viral shedding

Special considerations:

• Counsel all patients, including men, about the risk of neonatal infection 5
• HSV-1 causes 5-30% of first-episode genital herpes cases, with much less frequent clinical recurrences than HSV-2 1
• Identification of the infecting strain (HSV-1 vs HSV-2) has prognostic importance for counseling 1

Common Pitfalls to Avoid

• Never use topical acyclovir alone - it is substantially less effective than systemic treatment 5, 1
• Do not delay episodic treatment beyond 72 hours - efficacy decreases significantly 5
• Avoid delaying treatment beyond 24 hours for recurrences when possible 5
• Antiviral resistance is rare in immunocompetent patients but more common in immunocompromised individuals 1
• Single-day famciclovir does not shorten time to next recurrence or increase resistance risk 6