What is the recommended acute treatment for Herpes Simplex Virus (HSV) type 2 infection?

From the Guidelines

For acute treatment of HSV type 2, antiviral medications such as oral acyclovir, valacyclovir, or famciclovir should be used as first-line treatment. The treatment approach should prioritize reducing morbidity, mortality, and improving quality of life. According to the guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents 1, suppressive therapy with oral acyclovir, valacyclovir, or famciclovir is effective in preventing recurrences.

For acute treatment, the following medications can be used:

• Oral acyclovir 400 mg three times daily for 7-10 days
• Valacyclovir 1 gram twice daily for 7-10 days
• Famciclovir 250 mg three times daily for 7-10 days It is essential to start treatment as soon as possible after symptoms appear, ideally within 72 hours of outbreak onset, as antivirals work by inhibiting viral DNA replication and are most effective early in the infection 1.

In addition to antiviral medication, patients should also maintain good hygiene, wear loose clothing to prevent irritation, and avoid sexual contact until lesions have completely healed to prevent transmission. Pain management with acetaminophen or ibuprofen and sitz baths can help relieve discomfort. For recurrent episodes, the same medications may be used but often at shorter durations (typically 3-5 days) or as suppressive therapy if outbreaks are frequent, as recommended by the guidelines 1.

From the FDA Drug Label

The median time to lesion healing was 4 days in the group receiving VALTREX 500 mg versus 6 days in the placebo group, and the median time to cessation of viral shedding in subjects with at least 1 positive culture (42% of the overall trial population) was 2 days in the group receiving VALTREX 500 mg versus 4 days in the placebo group The median time to cessation of pain was 3 days in the group receiving VALTREX 500 mg versus 4 days in the group receiving placebo. In a third trial, subjects were randomized to receive VALTREX 500 mg twice daily for 5 days (n = 398) or VALTREX 500 mg twice daily for 3 days (and matching placebo twice daily for 2 additional days) (n = 402) The median time to lesion healing was about 4½ days in both treatment groups. The median time to cessation of pain was about 3 days in both treatment groups.

For the acute treatment of HSV type 2, the recommended treatment is:

• Valacyclovir (PO): 500 mg twice daily for 5 days or 500 mg twice daily for 3 days
• The median time to lesion healing is about 4 days, and the median time to cessation of pain is about 3 days 2
• Key points:
  • Valacyclovir reduces the median time to lesion healing and cessation of pain
  • Valacyclovir reduces the median time to cessation of viral shedding
  • The treatment regimen is 500 mg twice daily for 5 days or 500 mg twice daily for 3 days

From the Research

Treatment Options for Acute HSV Type 2

• The treatment of acute HSV type 2 infection typically involves antiviral medications, such as acyclovir, valacyclovir, or famciclovir 3, 4, 5.
• The choice of treatment depends on the severity of the infection, the patient's immune status, and the presence of any underlying medical conditions 3.
• For immunocompetent patients, standard oral acyclovir therapy is often initiated at a dose of 200 mg orally, five times a day for the first 3 to 5 days 3.
• If the response is poor, the dose of oral acyclovir may be increased to 800 mg five times a day, or alternative regimens such as topical trifluridine (TFT) or intravenous foscarnet may be considered 3.

Antiviral Medications

• Acyclovir is a commonly used antiviral medication for the treatment of HSV type 2 infection, and it is available in oral and intravenous forms 3, 5.
• Valacyclovir is a prodrug of acyclovir and has been shown to be effective in reducing the severity and duration of HSV type 2 infection 5.
• Famciclovir is another antiviral medication that has been shown to be effective in treating HSV type 2 infection, and it is available in oral form 4, 6.

Treatment Protocols

• The treatment protocol for acute HSV type 2 infection may involve intermittent episodic therapy, intermittent suppressive therapy, or chronic suppressive therapy, depending on the patient's clinical characteristics and preferences 4.
• Daily suppressive therapy with valacyclovir has been shown to reduce the risk of sexual transmission of HSV type 2 in HSV-2-serodiscordant heterosexual couples 7.
• However, the effectiveness of daily suppressive therapy with acyclovir in reducing the risk of HSV-2 transmission from HSV-2/HIV-1 coinfected persons is unclear 7.