What is the recommended management for a patient with a Herpes Simplex Virus type 2 (HSV-2) outbreak?

HSV-2 Outbreak Management

For an active HSV-2 outbreak, initiate oral antiviral therapy immediately with valacyclovir 1 gram twice daily for 7-10 days for first episodes, or valacyclovir 500 mg twice daily for 5 days for recurrent episodes, starting treatment within 24 hours of symptom onset for maximum effectiveness. 1, 2

Treatment Algorithm by Clinical Scenario

First Clinical Episode (Primary Outbreak)

Recommended first-line regimens (choose one): 3, 1

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

Key considerations for first episodes: 3, 1

• Extend treatment beyond 10 days if healing is incomplete 3, 1
• First episodes are typically more severe and prolonged than recurrences 3
• Symptomatic improvement should occur within 3 days, with objective improvement within 7 days 3

Recurrent Episodes (Episodic Therapy)

Recommended regimens for recurrences (choose one): 3, 2

• Valacyclovir 500 mg orally twice daily for 5 days (preferred) 2, 4
• Valacyclovir 1 g orally once daily for 5 days 3
• Acyclovir 400 mg orally three times daily for 5 days 3, 2
• Acyclovir 800 mg orally twice daily for 5 days 3, 2
• Famciclovir 125 mg orally twice daily for 5 days 2

Critical timing for episodic therapy: 3, 2

• Treatment must be initiated during prodrome or within 24 hours of lesion onset for maximum benefit 3, 2
• Delayed treatment beyond 72 hours significantly reduces effectiveness 2
• Provide patients with a prescription to self-initiate at first symptom 3
• Median time to lesion healing with valacyclovir 500 mg is 4 days versus 6 days with placebo 4

Suppressive Therapy (Chronic Daily Therapy)

Indications for suppressive therapy: 1, 2

• Patients with ≥6 recurrences per year 3, 1
• Patients desiring to reduce transmission risk to partners 1, 5
• Patients with severe psychological impact from recurrences 3

Recommended suppressive regimens (choose one): 1, 2

• Valacyclovir 500 mg once daily (for infrequent recurrences, <10/year) 1
• Valacyclovir 1 g once daily (for frequent recurrences, ≥10/year) 1, 4
• Acyclovir 400 mg twice daily 1, 2
• Famciclovir 250 mg twice daily 2

Efficacy of suppressive therapy: 3, 1, 4

• Reduces recurrence frequency by ≥75% 3, 1
• Reduces asymptomatic viral shedding by approximately 73% (from 10.8% to 2.9% of days) 5
• Reduces transmission to uninfected partners by 48-50% when combined with safer sex practices 4, 5
• After 1 year of continuous therapy, reassess need for continuation 3, 1

Special Populations

HIV-Infected Patients

Modified treatment approach: 3, 1

• May require longer treatment courses than HIV-negative patients 3
• Do not use short-course therapy (1-3 days) in HIV-infected patients 1
• For suppressive therapy: valacyclovir 500 mg twice daily 1
• Monitor closely for treatment failure and slower healing 3
• Acyclovir resistance more common in immunocompromised hosts 6

Pregnant Women

Antiviral safety in pregnancy: 1, 7

• Acyclovir is first-choice therapy with decades of safety data 1
• Episodic therapy can be offered during pregnancy for first episodes and recurrences 1
• Consider suppressive therapy starting at 36 weeks gestation to reduce viral shedding at delivery 1
• Cesarean delivery is recommended if visible lesions or prodromal symptoms present at labor onset 1

Elderly Patients

Dose adjustments required: 7

• Monitor renal function closely, as acyclovir and derivatives are renally excreted 7
• Adjust doses based on creatinine clearance 7
• Standard pain management with NSAIDs or acetaminophen for mild-moderate pain 7
• Short-term opioids may be necessary for severe pain during acute phase 7

Treatment Failure and Resistance

Suspect treatment failure if: 1, 2, 6

• Lesions do not begin to resolve within 7-10 days of appropriately dosed therapy 1, 2
• New lesions continue to form after 5-7 days of treatment 6

Management of suspected resistance: 1, 2, 6

• Obtain viral culture and HSV susceptibility testing 1, 2
• For confirmed acyclovir-resistant HSV: IV foscarnet 40 mg/kg every 8 hours is the treatment of choice 1, 2, 6
• Alternative: topical trifluridine (TFT) for accessible mucocutaneous lesions 6
• Resistance is rare in immunocompetent patients but more common in immunocompromised hosts 6

Escalation protocol for poor response: 6

• If no response to standard oral acyclovir 200 mg five times daily after 3-5 days, increase to 800 mg five times daily 6
• If no response after 5-7 days at high dose, switch to IV foscarnet rather than IV acyclovir 6

Adjunctive Symptomatic Management

Pain control strategies: 7

• NSAIDs (ibuprofen, naproxen) or acetaminophen as first-line for mild-moderate pain 7
• Topical lidocaine for local relief 7
• Sitz baths for genital lesions 7
• Short-term opioids for severe pain in acute phase 7

Monitoring requirements: 1, 2

• No laboratory monitoring needed for episodic or suppressive therapy unless substantial renal impairment exists 1, 2
• For high-dose IV acyclovir: monitor renal function at initiation and 1-2 times weekly during treatment 1

Critical Patient Counseling Points

Disease education: 3, 1, 4

• HSV-2 is not curable; antiviral therapy controls but does not eradicate latent virus 3, 4
• Recurrent episodes are common, especially in the first year after infection 3
• Asymptomatic viral shedding occurs and transmission can happen without visible lesions 3, 4

Transmission prevention: 3, 1, 4

• Abstain from sexual activity when lesions or prodromal symptoms are present 3, 4
• Use condoms consistently during all sexual exposures to reduce transmission risk by approximately 50% 1, 5
• Suppressive therapy reduces but does not eliminate transmission risk 1, 4
• Partners should be tested using type-specific serology and counseled about risks 1

Treatment initiation: 3, 4

• Initiate episodic therapy at earliest symptom (tingling, itching, burning) 4
• Keep medication on hand to start immediately at first sign of recurrence 3
• Treatment effectiveness decreases significantly if delayed beyond 24 hours 2

Common Pitfalls to Avoid

• Do not use topical acyclovir—it is substantially less effective than oral therapy and is not recommended 3, 2
• Do not delay treatment initiation—efficacy drops dramatically after 24 hours for recurrences and 72 hours for first episodes 3, 2
• Do not use short-course (1-3 day) regimens in HIV-infected patients—they are ineffective 1
• Do not assume suppressive therapy prevents all transmission—counsel patients that risk is reduced but not eliminated 1, 4
• Do not forget to adjust doses in renal impairment—all antivirals are renally excreted 7
• Do not continue ineffective therapy—if no improvement by 7-10 days, suspect resistance and obtain cultures 1, 2