Treatment for Recurrent Genital Herpes on the Mons Pubis
For this patient with recurrent genital herpes, initiate episodic antiviral therapy with valacyclovir 500 mg orally twice daily for 3 days, starting at the first sign of lesions or prodromal symptoms. 1, 2
Episodic Treatment Regimens
The most effective approach is to begin treatment during the prodrome or within 24 hours of lesion onset, as this is when viral replication peaks 1, 3. The CDC-recommended first-line options include:
- Valacyclovir 500 mg orally twice daily for 3 days (preferred for convenience and shorter duration) 1, 2
- Acyclovir 400 mg orally three times daily for 5 days 1
- Acyclovir 800 mg orally twice daily for 5 days 4
- Famciclovir 125 mg orally twice daily for 5 days 1
Critical timing consideration: Treatment initiated beyond 72 hours of lesion onset provides minimal benefit, so patients should be given a prescription to self-initiate therapy at the earliest symptom 3.
When to Consider Suppressive Therapy
If this patient experiences ≥6 recurrences per year, transition to daily suppressive therapy, which reduces recurrence frequency by ≥75% 4, 1. Suppressive regimens include:
- Valacyclovir 500 mg to 1 gram orally once daily (preferred) 1, 2
- Acyclovir 400 mg orally twice daily 4, 1
- Famciclovir 250 mg orally twice daily 1
Suppressive therapy has been documented as safe for up to 6 years with acyclovir and 1 year with valacyclovir 1. After 1 year of continuous suppression, consider discontinuing to reassess recurrence frequency 4.
Important Counseling Points
- Abstain from sexual activity when lesions or prodromal symptoms are present 4
- Use condoms during all sexual exposures, as asymptomatic viral shedding can occur and transmission is possible even without visible lesions 4, 1
- Inform sexual partners about the diagnosis 1
- Understand that antiviral therapy controls symptoms but does not eradicate the virus or prevent all recurrences 1
Common Pitfalls to Avoid
- Never use topical acyclovir alone—it is substantially less effective than oral therapy 1, 3
- Do not delay treatment beyond 72 hours of symptom onset, as efficacy diminishes significantly 3
- Suspect acyclovir resistance if lesions do not begin to resolve within 7-10 days of appropriately dosed therapy; consider switching to IV foscarnet 40 mg/kg every 8 hours 1, 5
- Avoid valacyclovir 8 grams per day in immunocompromised patients due to risk of hemolytic uremic syndrome/thrombotic thrombocytopenic purpura 1
Special Considerations
For elderly patients or those with renal impairment, monitor renal function and adjust antiviral doses based on creatinine clearance, as these medications are renally excreted 5. If persistent discharge or pelvic pain accompanies the lesions, evaluate for concurrent infections 1.