What is the recommended treatment for recurrent genital herpes outbreaks?

Treatment of Recurrent Genital Herpes Outbreaks

For recurrent genital herpes outbreaks, start episodic antiviral therapy with valacyclovir 500 mg orally twice daily for 3-5 days, initiated at the first sign of prodrome or within 24 hours of lesion onset. 1, 2

Episodic Treatment Regimens

The CDC provides multiple effective options for treating recurrent outbreaks, all of which should be started during prodromal symptoms or within 1 day of lesion appearance for maximum effectiveness 1:

First-line options:

• Valacyclovir 500 mg orally twice daily for 3 days (FDA-approved shortest duration) 2
• Valacyclovir 500 mg orally twice daily for 5 days 1
• 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

Key timing principle: Episodic therapy is most effective when started during the prodrome or within 1 day after onset of lesions, as peak viral replication occurs in the first 24 hours 1, 3. Treatment initiated beyond 72 hours shows substantially reduced effectiveness 3.

When to Consider Suppressive Therapy

Switch to daily suppressive therapy if patients experience ≥6 recurrences per year 1, 4. Suppressive therapy reduces recurrence frequency by ≥75% and decreases asymptomatic viral shedding 1, 4.

Suppressive regimens:

• Valacyclovir 1 gram orally once daily (standard dose) 1
• Valacyclovir 500 mg orally once daily (alternative for patients with ≤9 recurrences/year) 1, 2
• Acyclovir 400 mg orally twice daily 1
• Famciclovir 250 mg orally twice daily 1

Duration and reassessment: The CDC recommends discontinuing suppressive therapy after 1 year to reassess recurrence frequency, as outbreak frequency often diminishes over time 4. Acyclovir has documented safety for up to 6 years of continuous use, while valacyclovir and famciclovir have documented safety for 1 year 4.

Critical Pitfalls to Avoid

• Never use topical acyclovir alone—it is substantially less effective than oral therapy 1, 3
• Do not use valacyclovir 8 grams per day in immunocompromised patients due to risk of hemolytic uremic syndrome/thrombotic thrombocytopenic purpura 1
• Suspect acyclovir resistance if lesions do not begin to resolve within 7-10 days of therapy; consider foscarnet 40 mg/kg IV every 8 hours for proven or suspected resistance 1
• Avoid delaying treatment beyond 24-72 hours of symptom onset, as efficacy drops significantly 1, 3

Patient Counseling Requirements

Patients must understand that 1:

• Genital herpes is a recurrent, incurable viral disease
• Antiviral medications control symptoms but do not eradicate the virus or prevent all recurrences
• Asymptomatic viral shedding can occur even on suppressive therapy, potentially leading to transmission
• Abstain from sexual activity when lesions or prodromal symptoms are present
• Inform sex partners about having genital herpes
• Use condoms during all sexual exposures with new or uninfected partners

Extended Treatment Considerations

If symptoms persist beyond 5 days of treatment, consider extended therapy and evaluate for potential co-infections, particularly if discharge and pelvic pain are present 1.