What is the recommended treatment for an adult patient with a normal immune system and genital herpes?

Treatment of Genital Herpes in Immunocompetent Adults

For an adult patient with normal immune function and genital herpes, the CDC recommends oral antiviral therapy with valacyclovir, acyclovir, or famciclovir, with specific regimens depending on whether this is a first episode, recurrent outbreak, or requires suppressive therapy. 1, 2

First Clinical Episode

For initial genital herpes infection, treat with oral antivirals for 7-10 days: 2

• Valacyclovir 1 g orally twice daily for 7-10 days (preferred for convenience) 2, 3
• Acyclovir 400 mg orally three times daily for 7-10 days 2
• Acyclovir 200 mg orally five times daily for 7-10 days 2
• Famciclovir 250 mg orally three times daily for 7-10 days 2

Critical timing consideration: Treatment should ideally be initiated within 72 hours of symptom onset for maximum effectiveness, though the FDA notes efficacy beyond this window has not been established. 3 Extend therapy beyond 10 days if healing remains incomplete. 2

Recurrent Episodes (Episodic Therapy)

For recurrent outbreaks, treat with shorter 5-day courses: 1

• Valacyclovir 500 mg orally twice daily for 5 days (most convenient option) 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, 4

Episodic therapy is most effective when started during prodrome or within 1 day after lesion onset. 1, 2 Provide patients with a prescription or medication supply to self-initiate treatment at the first sign of tingling, itching, burning, or lesions. 2 The FDA notes that efficacy when initiated more than 24 hours after symptom onset has not been established. 3

Suppressive Therapy (Daily Maintenance)

For patients with frequent recurrences (≥6 episodes per year), the CDC recommends daily suppressive therapy: 1, 2

• Valacyclovir 1 g orally once daily 1, 3
• Valacyclovir 500 mg orally once daily (may be less effective with ≥10 episodes/year) 1, 5
• Acyclovir 400 mg orally twice daily 1
• Famciclovir 250 mg orally twice daily 1, 4

Suppressive therapy reduces recurrence frequency by ≥75% and decreases asymptomatic viral shedding. 1, 2 Safety has been documented for acyclovir up to 6 years and for valacyclovir/famciclovir up to 1 year. 1, 3, 4 After 1 year of continuous suppression, consider discontinuing therapy to reassess recurrence frequency. 1, 2

Critical Pitfalls to Avoid

Never use topical acyclovir—it is substantially less effective than oral therapy and does not improve systemic symptoms. 1, 2, 5 The CDC explicitly recommends against topical formulations. 1

Do not use valacyclovir 8 grams per day in any patient, as this dose is associated with hemolytic uremic syndrome/thrombotic thrombocytopenic purpura in immunocompromised individuals. 1

Suspect acyclovir resistance if lesions fail to begin resolving within 7-10 days of therapy—though this is rare in immunocompetent patients, it warrants consideration of foscarnet 40 mg/kg IV every 8 hours. 1

Essential Patient Counseling

Patients must understand that genital herpes is a chronic, incurable viral infection: 1

• Antivirals control symptoms but do not eradicate the virus or prevent all recurrences 1
• Asymptomatic viral shedding occurs and can lead to transmission even without visible lesions 1, 2
• Abstain from sexual activity when lesions or prodromal symptoms are present 1, 2
• Inform all sexual partners about the diagnosis 1, 2
• Use condoms during all sexual exposures with new or uninfected partners 1, 2
• Women of childbearing age should inform healthcare providers about HSV infection if pregnant 2

HSV-1 vs HSV-2 Considerations

Identifying the infecting strain has prognostic importance: 2

• HSV-2 causes more frequent recurrences and asymptomatic shedding than HSV-1 2
• HSV-1 accounts for 5-30% of first-episode genital herpes but recurs much less frequently 2
• Clinical recurrences are significantly less common with genital HSV-1 infection 2