What is the recommended treatment for a patient presenting with genital issues, such as genital warts or genital herpes?

Treatment of Genital Issues

Genital Herpes Treatment

For genital herpes, treat first episodes with valacyclovir 1 g orally twice daily for 7-10 days, and manage recurrent episodes with episodic therapy (valacyclovir 500 mg twice daily for 5 days) or daily suppressive therapy (valacyclovir 500 mg to 1 g once daily) for patients with ≥6 recurrences per year. 1

First Clinical Episode

• Initiate antiviral therapy immediately with one of the following CDC-recommended regimens 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
  • Acyclovir 200 mg orally five 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, as lesions may require additional time to resolve completely 1

• For severe disease requiring hospitalization, use acyclovir 5-10 mg/kg IV every 8 hours for 5-7 days or until clinical resolution 1

Recurrent Episodes: Episodic Therapy

• Start treatment during prodrome or within 24 hours of lesion onset for maximum efficacy 1, 3

• Provide patients with medication or prescription in advance so they can self-initiate treatment at first symptoms 1

• Recommended episodic regimens (5-day courses) 1:

  • Valacyclovir 500 mg orally twice daily 1, 2
  • Acyclovir 400 mg orally three times daily 1
  • Acyclovir 800 mg orally twice daily 1
  • Famciclovir 125 mg orally twice daily 1

Suppressive Therapy

• Initiate daily suppressive therapy for patients with ≥6 recurrences per year to reduce recurrence frequency by ≥75% 1, 3

• Recommended suppressive regimens 1:

  • Valacyclovir 1 g orally once daily (preferred for once-daily dosing) 1, 4
  • Valacyclovir 500 mg orally once daily 1
  • Acyclovir 400 mg orally twice daily 1
  • Famciclovir 250 mg orally twice daily 1

• Reassess after 1 year of continuous therapy by discontinuing suppressive treatment to determine current recurrence frequency 1

• Safety is established for acyclovir up to 6 years and for valacyclovir/famciclovir for 1 year 1

Critical Treatment Principles

• Never use topical acyclovir, as it is substantially less effective than oral therapy 1, 3

• Identify HSV-1 versus HSV-2 when possible, as HSV-1 causes 5-30% of first-episode genital herpes but recurs much less frequently than HSV-2 1

• For immunocompromised patients, use higher doses (acyclovir 400 mg orally 3-5 times daily until clinical resolution) 1

• If lesions persist despite treatment in immunocompromised patients, suspect acyclovir resistance and consider foscarnet 40 mg/kg IV every 8 hours 1

Essential Patient Counseling

• Counsel about natural history: potential for recurrent episodes, asymptomatic viral shedding, and sexual transmission 1

• Abstain from sexual activity when lesions or prodromal symptoms are present 1

• Use condoms during all sexual exposures with new or uninfected partners 1

• Inform sex partners about having genital herpes 1

• Explain that antivirals control symptoms but do not eradicate the virus or prevent all recurrences 1

• For women of childbearing age, discuss risk of neonatal infection and importance of informing healthcare providers during pregnancy 1

Genital Warts Treatment

For genital warts, use patient-applied imiquimod cream 3 times per week for up to 16 weeks, or clinician-applied treatments such as cryotherapy or trichloroacetic acid for immediate lesion destruction. 5, 6

Patient-Applied Treatments

• Imiquimod 5% cream applied 3 times per week (Monday, Wednesday, Friday or alternate nights) for up to 16 weeks 5, 6:

  • Wash treatment area with mild soap and water 6-10 hours after application 5
  • Continue until total clearance or maximum 16 weeks 5
  • Common local reactions include erythema, erosion, excoriation/flaking, and edema 5

• Podofilox 0.5% solution or gel applied twice daily for 3 days, followed by 4 days off, for up to 4 cycles 6

• Sinecatechins 15% ointment applied three times daily for up to 16 weeks 6

Clinician-Applied Treatments

• Cryotherapy with liquid nitrogen repeated every 1-2 weeks until lesions resolve 6

• Trichloroacetic acid (TCA) or bichloroacetic acid (BCA) 80-90% applied directly to warts, repeated weekly as needed 6

• Podophyllin resin 10-25% applied to warts, washed off after 1-4 hours, repeated weekly 6

• Surgical excision, electrosurgery, or laser therapy for large or refractory lesions 6

Critical Warnings for Genital Warts

• Avoid sexual contact while cream is on the skin, as imiquimod may weaken condoms and vaginal diaphragms 5

• Do not apply imiquimod inside the vagina (considered internal use) 5

• Women should monitor for difficulty urinating if applying cream near vaginal opening, as local reactions on moist surfaces can cause pain and swelling 5

• Uncircumcised males treating warts under foreskin should retract foreskin and clean area daily 5

• New warts may develop during therapy, as treatment is not a cure 5

• Minimize sun exposure and use sunscreen during treatment 5

• If severe local skin reaction occurs, remove cream by washing with mild soap and water 5