What is the recommended treatment for a patient with herpes simplex virus (HSV) infection?

Treatment for Herpes Simplex Virus (HSV) Infection

For first-episode HSV, treat with valacyclovir 1 gram orally twice daily for 7-10 days, starting within 48 hours of symptom onset for maximum effectiveness. 1, 2

First Clinical Episode Treatment

The treatment approach differs significantly based on whether this is a first episode versus recurrent infection, and the anatomic site involved.

Genital Herpes - First Episode

• Valacyclovir 1 gram orally twice daily for 7-10 days is the preferred first-line treatment 1, 2
• Alternative regimens include:
  • Acyclovir 400 mg orally three times daily for 7-10 days 1, 2
  • Acyclovir 200 mg orally five times daily for 7-10 days 1, 2
  • Famciclovir 250 mg orally three times daily for 7-10 days 1, 2
• Treatment must be initiated within 48 hours of symptom onset for optimal efficacy 1

Orolabial Herpes - First Episode

• Valacyclovir 500 mg orally twice daily for 5 days initiated at first sign of outbreak 2

Herpes Proctitis

• Acyclovir 400 mg orally five times daily for 10 days or until clinical resolution 2

Recurrent Episode Treatment

For recurrent infections, shorter treatment courses are appropriate when initiated early.

Episodic Therapy for Recurrent Genital Herpes

• Valacyclovir 500 mg orally twice daily for 3 days is preferred for convenience 1
• Alternative 5-day regimens include:
  • Acyclovir 400 mg orally three times daily 1, 2
  • Acyclovir 800 mg orally twice daily 1, 2
  • Famciclovir 125 mg orally twice daily 1, 2
• Treatment is most effective when started during prodrome or within 24 hours of lesion onset 1, 2, 3
• Delaying treatment beyond 72 hours significantly reduces effectiveness 3

Patient-Initiated Therapy Strategy

• Provide patients with a prescription for antiviral medication to self-initiate at the first sign of recurrence 3
• This allows treatment within the narrow therapeutic window early in the infection episode 4

Suppressive Therapy

Daily suppressive therapy represents a paradigm shift for patients with frequent recurrences.

Indications for Suppressive Therapy

• Patients with ≥6 recurrences per year should receive daily suppressive therapy 1, 2, 3
• Patients seeking to reduce transmission risk to uninfected partners 2
• Suppressive therapy reduces recurrence frequency by ≥75% 1, 2, 3
• Decreases asymptomatic viral shedding, reducing transmission risk 3

Suppressive Regimens

• Valacyclovir 1 gram orally once daily (preferred for convenience) 1, 2, 3
• Valacyclovir 500 mg orally once daily (for patients with ≤9 recurrences per year) 1, 2, 3
• Acyclovir 400 mg orally twice daily 1, 2, 3
• Famciclovir 250 mg orally twice daily 1, 2, 3

Duration and Reassessment

• After 1 year of continuous suppressive therapy, discontinue treatment to reassess recurrence frequency 3
• Suppressive therapy has documented safety for up to 6 years with acyclovir and 1 year with valacyclovir 3

Special Populations

Immunocompromised Patients

• Higher doses are required: acyclovir 400 mg orally three to five times daily until clinical improvement 1
• For severe initial genital herpes episodes, IV acyclovir is indicated 5
• Treatment duration of 5-14 days for genital HSV in HIV-infected patients 2
• For patients with inflammatory bowel disease, consider oral suppressive antiviral therapy at the start of or during immunomodulator therapy 1

Acyclovir-Resistant HSV

• Suspect resistance if lesions do not begin to heal after 7-10 days of treatment 1
• Foscarnet 40 mg/kg IV every 8 hours is the treatment of choice for proven or suspected resistance 1, 2
• Alternative: topical trifluorothymidine applied three to four times daily for accessible lesions 6
• If foscarnet fails, consider IV cidofovir or topical cidofovir 1-3% ointment 6

Critical Patient Counseling Points

Disease Education

• Inform patients that genital herpes is a recurrent, treatable, but incurable viral disease 1
• Antiviral medications control symptoms but do not eradicate the virus or prevent all recurrences 1
• Asymptomatic viral shedding can occur even without visible lesions and lead to transmission 1, 2, 3

Transmission Prevention

• Avoid sexual activity when lesions or prodromal symptoms are present 1, 2
• Use condoms consistently during all sexual contact with new or uninfected partners 2, 3
• Sexual partners should be informed about HSV infection 1
• Advise about risk of neonatal infection 3

Common Pitfalls to Avoid

• Never use topical acyclovir alone—it is substantially less effective than systemic treatment 3
• Do not initiate suppressive therapy in patients with <6 recurrences per year, as the benefit does not justify continuous medication 3
• Do not withhold episodic treatment prescriptions even if the patient is not on suppressive therapy 3
• Most immunocompetent patients with infrequent recurrent disease do not benefit from continuous antiviral therapy 3
• Asymptomatic HSV carriers without active lesions do not require antiviral treatment 3

Monitoring

• No laboratory monitoring is needed for patients receiving episodic or suppressive therapy unless substantial renal impairment is present 2