Treatment of First-Episode Acute Genital Herpes
For a first episode of acute genital herpes in an otherwise healthy adult, initiate oral antiviral therapy immediately with valacyclovir 1 g twice daily for 7–10 days. 1
First-Line Treatment Regimens
The CDC recommends any of the following oral antiviral regimens for first-episode genital herpes, all of which are equally effective: 1
- Valacyclovir 1 g orally twice daily for 7–10 days (preferred for convenience) 1, 2
- Acyclovir 400 mg orally three times daily for 7–10 days 1
- Acyclovir 200 mg orally five times daily for 7–10 days 1
- Famciclovir 250 mg orally three times daily for 7–10 days 1
Extend therapy beyond 10 days if lesions have not completely healed, as incomplete healing at day 10 warrants continued treatment. 1
Timing of Initiation
Start antiviral therapy as soon as possible after symptom onset—ideally within 48 hours—to achieve maximal reduction in symptom duration, viral shedding, and time to lesion healing. 1, 3, 4 Treatment initiated within the first 3 days of symptom appearance significantly shortens the duration of the first episode. 5
Severe Disease Requiring Hospitalization
For severe first-episode genital herpes with complications (disseminated infection, meningitis, hepatitis, or inability to tolerate oral therapy), administer acyclovir 5–10 mg/kg IV every 8 hours for 5–7 days or until clinical resolution is achieved. 1
Critical Patient Counseling Points
Provide comprehensive counseling at the time of diagnosis: 1
- Genital herpes is a chronic, lifelong viral infection with potential for recurrent episodes despite treatment. 1
- Antiviral medications control symptoms but do not eradicate the virus or prevent all future recurrences. 1
- Asymptomatic viral shedding occurs even without visible lesions, posing ongoing transmission risk; this is more frequent with HSV-2 than HSV-1 and during the first 12 months after infection. 1
- Abstain from all sexual activity when lesions or prodromal symptoms (tingling, burning, itching) are present. 1
- Use condoms consistently during all sexual exposures with new or uninfected partners, though condoms do not eliminate transmission risk entirely. 1
- Inform all sexual partners about the herpes diagnosis. 1
- Women of childbearing age must understand the risk of neonatal transmission, which is 25–44% with a primary episode at delivery versus ≈1% with recurrent infection. 1
Type-Specific Prognostic Information
Obtain HSV type-specific testing (HSV-1 vs. HSV-2) when possible, as this has important prognostic implications: 1
- HSV-1 causes 5–30% of first-episode genital herpes but results in far fewer clinical recurrences than HSV-2. 1
- HSV-2 genital infections recur more frequently and are associated with more frequent asymptomatic viral shedding. 1
Planning for Recurrences
Provide patients with a prescription for episodic antiviral therapy to self-initiate at the first sign of a recurrence (prodrome or within 24 hours of lesion onset), as early treatment is most effective. 1, 3 For recurrent episodes, the recommended regimen is valacyclovir 500 mg twice daily for 3–5 days. 1, 2
Consider daily suppressive therapy (valacyclovir 500 mg to 1 g once daily) for patients who experience ≥6 recurrences per year, which reduces recurrence frequency by ≥75%. 1 After 1 year of continuous suppressive therapy, reassess recurrence frequency, as the natural history often shows declining recurrence rates over time. 1
Common Pitfalls to Avoid
- Do not use topical acyclovir, as it is substantially less effective than oral systemic therapy. 1, 3
- Do not delay treatment initiation waiting for laboratory confirmation; begin therapy based on clinical presentation. 1
- Do not use standard-dose therapy in immunocompromised patients, who require higher doses (acyclovir 400 mg orally 3–5 times daily) and longer treatment courses. 1
- Assess renal function before starting and during therapy, adjusting dosing frequency according to creatinine clearance to avoid toxicity. 1